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Nic Report on Guard Death at Monroe Corr Center Wa 2011

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NIC Review Team Report
Washington Department of Corrections
Monroe Correctional Complex
Washington State Reformatory

Incident Review of Death of Correctional Officer Jayme Biendl
January 29, 2011

March 2011


Table of Contents

Executive Summary


Pre-planning Agenda


Documents Reviews


Staff Interviews


Briefing and Report Out


Team‟s Areas of Critical Review


Findings and Recommendations


Staff Comments



Executive Summary

Eldon Vail, Secretary, Washington Department of Corrections (WDOC) submitted a
request for the National Institute of Corrections (NIC) to conduct an independent review
of Monroe Correctional Complex/Washington State Reformatory into pertinent systems
and policies surrounding the policies and procedures relative to the death of
Correctional Officer Jayme Biendl which occurred on January 29, 2011.
The Review Team consisted of NIC consultants, Joan Palmateer, Lead Consultant,
James Upchurch, and Michelle Elzie. The Review Team was on site at the Monroe
Correctional Complex (MCC), Washington State Reformatory (WSR) in Washington
February 27, 2011 - March 4, 2011.
The report identifies systems, policies, practices, protocol, and technology within
MCC/WRS which would reasonably have been connected to factors surrounding safety
and security for staff and others within that compound.
It is important to note that the Review Team did not have access to the Chapel of the
facility because it was still considered a crime scene and active for the criminal
investigation. We did review the schematic of the entire chapel area to include camera
placement or lack thereof.
The research, review of documents, interviews, and work formulating our conclusion
and recommendations are in our opinion as Corrections Professionals opportunities to
mitigate safety and security vulnerabilities. There were numerous documents which
could not be viewed due to the ongoing criminal investigation. The recommendations
may not only impact Monroe Correctional Complex, but the entire Washington
Department of Corrections. Policies reviewed were generally department wide policies.
It may be noted that beyond the department policy, there are often varying
interpretations of how policy is carried out within each specific facility. There are
reasons this occurs: physical plant differences in each facility, inmate visibility,
inconsistent practices based on shift or supervisor expectations, security or custody
levels, staffing accommodations, or even correctional staff interpretation of policy.
Complacency can exist among corrections staff at every level which may lull them
into a false sense of security. Recognizing that complacency occurs periodically in all
correctional environments is important.
Change of policy or processes will require considerations not limited to:
communication, budget, and training. The consideration for how fast these changes
occur should be accomplished based on prioritization from most critical to those with
less risk factors associated.


We want to make special note that balancing programs with safety and security can
still be accomplished. Every medium custody institution must have rehabilitation or
reformation programs, and activities to provide opportunities for those inmates who will
eventually return to the community. The balance is a delicate one; however, if the
security and safety systems are designed to mitigate the risks associated with these
programs/activities there can be enhanced security within the correctional environment.
The “how” we accomplish those systems and practice safe operational protocol is what
determines the safety level within the correctional environment. We also recognize
there is no perfect system with all the answers on how to protect everyone, all the time,
everyplace. We work in an environment which is inherently more dangerous than the
average job.
The culture of an institution and how all staff responds to the entire operation and
each other is as integral as the written policies and procedures.
Pre-Planning Meeting / Draft-February 11, 2011
Joan Palmateer met with Secretary Eldon Vail, Director of Prisons, Bernie Warner,
and Deputy Secretary, Dan Pacholke on Friday February 11, 2011 for pre-planning
for review request.
Central Office staff and Monroe Correctional Complex staff.
Monroe Correctional Complex/ Washington State Reformatory
Chapel (specifically)
Review Chronology of Events:
• Time Inmate Schref arrives in Chapel
• Time Officer Jayme Biendl arrives in Chapel
• Last radio communication with Officer Jayme Biendl
• Last staff contact with Officer Jayme Biendl
• Count time (inmate discovered missing)
• Time of key and radio check from previous shift
• Inmate movement logs for day of incident
• Time of Officer Death
• Notification to shift management and Central office
• Notification to Medical Examiner
• Notification to police
• Securing of the Crime Scene
• Notification to other staff on shift
• Employee Assistance for staff affected


Security Policy/Protocol Review:
• Count
• Inmate Work Assignments
• Inmate Movement


Emergency Plans
Chapel supervision schedule
Communication equipment (radios, alarms etc.) (mandatory call-ins)
Key Control
Accounting for staff (shift to shift)
Available logs, records pertaining to day‟s activities
Camera placement and monitoring process from Chapel
Specific officer safety training
Personal body alarm system that may have been considered/available and/or
any panic alarm,
Procedure requirement for 30 minute security/safety/alertness calls to control,
response requirements

• Last day on site with Central Office, and Monroe staff
Written Review Report to be submitted by March 19, 2011 for review to BeLinda
Watson, Chief, Prisons Division, NIC and Eldon Vail, Secretary, Washington
Department of Corrections.

On Site Review: February 28-March 4, 2011
Inmate Byron Scherf - Hard file
WDOC Official Memos on Staff Member‟s Death
MCC Facility Information 2010
Published News Reports on Incident
Emergency Management Assessment 2010
Operations Inspection Report 7/2010
DOC Human Resource Management Report
WSR Demographics and Data
Training Program Information
2009 Employee Satisfaction Survey Briefing
Prison Management Expectations
Classification and Custody Policies
Risk and Needs Assessment
Incident and Specific Event Reporting
Post Orders and Post Logs
Radio System Operation and Acquisition
Callout Systems and Rosters
Searches of Offenders
Security Inspections
Key Control
Religious Programs

Work Programs
Escape Preparedness
Facility Lockdown Procedure
MCC Custody Post Audit
Chapel Schedule
Recent Directive Changes incorporated since incident
Various other logs, documents, forms, memos and policies
Staff Interviews
It should be noted that we interviewed many staff for specific information and
understanding relating to policy and operational practice at MCC/WSR. Some staff
did not to be identified by name.
We were not able to interview some staff because to do so may interfere with the
criminal investigation. We did allow staff to discuss their concerns or issues if they
thought there were security enhancements which may be needed. We have
provided a synopsis of those issues at the end of this report.
Michelle Wood
Alma Kingstad
Chaplain H. Fisher
Marjorie Peterson
Anna Williams
Karen Portin
Robert Pittzenberger
David Bustanoby
John Padilla
Lindsey Robinson
Lesley Chu
Captain Hardina
Sgt. Knox
Officer Jensen
Jonathon Johnson
Officer Parker
Todd Brown
Mr. Claussen
Two female industries staff
PAB Officers
We also discussed security protocols with various custody staff at their duty stations
Briefing and Report-Out
Review team met with Monroe Correctional Complex Management team and Central
Office Administrators February 28, 2011 to discuss how the week would progress.
We were assigned a liaison from Central Office; Devon Schrum, to assist with


whatever needs we had from central office. Michelle Wood was assigned as our
Monroe Correctional Complex liaison for the needs required from MCC/WSR.
Management team attending the briefing:
Dan Pacholke, Deputy Secretary
Bernie Warner, Director of Prisons
Scott Frakes, Superintendent
Karen Portin, Associate Superintendent
David Bustanoby, Associate Superintendent
Bryan Hardina, Captain
Kenneth Bratten, Captain
Annie Williams, Correctional Program Manager (CPM)
Michelle Wood, Correctional Program Manager (CPM)
Eric Harding, CMHMP
Marc Glaser, (recorder) CMHMS
Angela Loresch, Superintendent Support
Review Team Primary Areas of Critical Review
Joan Palmateer:
• Movement Call-outs passes, main line, unit control protocols, job
• Change process/follow through on directives
• Change process, lack of presence, supervisor oversight
• Cameras, placement, visibility, needs
• Post Orders, conflicting information
• Visibility, building and “stuff” removal
• Security Audit from outside for all three complexes
• Gate 7 criteria for inmates assigned
• Inmate Scherf or other inmates as volunteer clerks
James Upchurch:
• Officer Safety training program
• Tower
• Staffing
• Radio
• Personal Body Alarms
• Chemical Agents
Michelle Elzie:
• Classification
• Accountability for all staff, contractors and volunteers inside compound at end
of each shift, hours of work duty.


Findings and Recommendations
We were all most impressed with the sanitation level that we observed at MCC/WSR
despite the fact that they had been in various stages of lock down since the incident
prior to our arrival. A high level of sanitation in a correctional facility is indicative of
the management and supervisors‟ ability to “get things done” through their staff as
well as all of the staff‟s ability to require the inmates to regularly perform all the tasks
associated with maintaining sanitation in a prison environment and to perform these
tasks at a high level of proficiency. This speaks well for the overall health of the
Washington State Reformatory (WSR).
Staff Assaults
We reviewed the staff assaults that have occurred at MCC/WSR since 2006 in order
to make a determination of the relative frequency and severity of such incidents at
WSR compared to other similar facilities in other jurisdictions with which we are
familiar. It is important to point out that a staff assault as defined in most correctional
jurisdictions today can range anywhere from such incidents, noted at WSR, as an
inmate throwing his ID card into the chest of an officer to pushing an officer‟s hand
away when he is retrieving contraband and to actually placing a staff member in a
head lock when angered at a response. Our review revealed that staff assaults in
general at MCC/WSR as reported to us have diminished significantly over the last
five years. The frequency and overall seriousness of such incidents are not
inconsistent with the level that would be expected in a facility such as MCC/WSR nor
are they inconsistent with the level found in other jurisdictions with which we are
This is not to say that security operational practices cannot and should not be
enhanced in areas relative to such an incident. It is a well known fact that working in
corrections is always a career that you come into with an understanding of the ever
present danger of working with sometimes violent offenders. As with the community,
we never really know what goes on in the mind of other persons whether
incarcerated or not.



Treatment/Program - Custody/Control Balance;
It is important that a balanced emphasis exist in a correctional institution, particularly
a facility such as MCC/WSR that houses some 137 inmates sentenced to life without
parole (LWOP) for a variety very serious, violent offenses. An environment that is
conducive for effective program and treatment opportunities for inmates does not
and should not be one devoid of structure, discipline and control. Inmates should be
encouraged and given the opportunity to take personal responsibility for their
behavior within an environment structured to the extent necessary to provide for
order and safety for all. Adequate control and discipline must be exercised by the
staff when inmates fail to follow the rules and must be applied in a fair, firm and
consistent manner. Failure by the facility to provide the necessary level of control
and discipline is detrimental to safety and security for everyone in the facility and
also serves to the detriment of the appropriate and successful delivery of the

Recommendation 1
It appears to us that to attain the appropriate balance at WSR some emphasis shift
toward increased inmate accountability and control is indicated. Security staff
concerns and issues should be carefully considered and implemented when
determined to be legitimate and appropriate. If not implemented, the reason for not
doing so should be thoroughly explained. Accommodation measures implemented
solely for inmate preference, convenience and comfort should receive a low priority
when considered in light of staffing limitations related to insuring that inmate
movement and behavior is carefully monitored and controlled to maintain a safe and
secure environment.
We note in the executive summary that to achieve that balance, the security and
safety systems and practices must be enhanced to allow safe programs conducive
to inmate reformation opportunities while still providing structure and control.
Security is dynamic, and as such it is ever changing so as program needs change,
so should the security policy and practices.

Communication and Alarm
There is no personal body alarm (PBA) system at the MCC/WSR. Uniformed staff
must depend on direct verbal notification when possible, telephone and/or their
assigned portable radio to alert control and other staff to an immediate need for
assistance should they be assaulted or should the threat of assault be imminent.


The radio system does feature an alert capability in addition to the normal radio
transmission capability associated with depressing the microphone key and
communicating verbally the need for assistance, location and identity of the
transmitting officer. This alert capability audibly signals the control room area where
the radio control station is located and simultaneously keys the microphone on the
portable radio („hot mic‟) possessed by the officer to transmit for a prescribed time
period and override all other radio traffic to allow control and other radios tuned to
the same talk group to hear any verbal/audible activity that may be occurring in the
immediate vicinity of the radio. This function is initiated by depressing a small red
button just proximal to the antennae connection point to the body of the radio.
These options in many cases are sufficient to allow an officer to acquire assistance
when it is needed. There are, however, concerns with depending on these options
alone that are addressed with the installation of a PBA system and discussed below.
These concerns are magnified in the case of non-uniformed/custody staff who are
not issued a portable two-way radio and must depend on the telephone and/or
shouting or screaming for assistance.

Recommendation 2
We recommend the installation of a personal body alarm system that when activated
automatically alerts the institution main control room and provides the name of the
officer and the officer‟s location within the institution -the current capability
associated with the radio system described in the finding above only alerts to the
specific radio from which the alert was received and not the name of the staff
member or the location from the which the alert emanated. If desired the system can
be integrated with the radio system to immediately announce from the radio console
the alert and associated information to all staff on the talk group being utilized.
There are several vendors that can provide such a system thus fostering a
competitive procurement process to hold down costs. It is recommended that the
system selected include only those features required to make it functional to
accomplish only what is necessary to provide for enhanced staff safety. This would
include that the system be self-monitoring in terms of alerting control room staff
when transmitter battery strength is low and if, for any other reason, a transmitter or
receiver becomes dysfunctional. The system with which we are most familiar alerts
when either a button is depressed on the transmitter worn by the staff member or
when a lanyard attached to both the transmitter and to the belt or clothing of the
wearer is dislodged by an inmate pulling the transmitter away from the staff member
in an effort to keep them from depressing the alert button.
There are systems that feature transmitters worn by the staff that alert when the
orientation angle of the transmitter to perpendicular changes significantly indicating
that the staff wearing it has fallen or been forced or knocked to the ground. The
issue of false alarms has served to dissuade many users from this feature.


For cost containment purposes the agency may also consider location specificity of
the PBA system be limited to general zones or areas such as designated living
areas and/or zones/sectors within large buildings such as industries at MCCWSR.
For example, as opposed to the expensive requirement that the PBA alert system
provide the location of an officer needing assistance in a cell block to within a 15 foot
area and/or distinguish which tier level he/she is located, it is sufficient that the
system simply advise that the officer needs assistance in a block to allow response
staff to locate him/her in that area. Similarly, instead of requiring that the system
provide the specific office from which an alert is transmitted from the programs area
building (PAB) at MCC/WSR, two area/zone locations encompassing the main
hallways would be sufficient.
We are available to assist your department further in developing the specifications
for a system that is effective while simultaneously cost efficient in recognition of the
difficult fiscal times impacting all of us in state government.

Chemical Agents
Uniformed custody staff are not issued and subsequently do not carry on their
person any force multiplier option for their own defense in case of imminent or actual
physical assault or to rescue/defend fellow staff or inmates from such assaults. Staff
currently must rely exclusively on physical, hands on force options in such cases
when non-force options fail.
While it is certainly true that the training provided to staff annually on defensive
tactics is beneficial, it is generally known that proficiency in the tactics taught cannot
be achieved in the limited training time designated for this purpose. A review of the
training curriculum provided to custody staff in the Washington State Department of
Corrections would also appear to support this observation. Additionally, the absence
of physical fitness requirements can result in poorly conditioned staff being pitted
against physically superior inmates in situations where staff personal safety is in
Physical, hands on confrontation with inmates also has the additional risk associated
with the well-established higher prevalence of communicable diseases such as HIV
and hepatitis C within the inmate population cuts, abrasions, etc. that allow for
contact with bodily fluids during a physical struggle with an inmate pose a significant
risk to staff.
Staff physical injuries sustained in hands-on struggles with inmates also frequently
result in extended medical leave requirements and expensive workmen‟s
compensation claims and medical expenses in addition to the associated pain and
suffering such injuries can cause.

Recommendation 3
We recommend that all custody staff, be issued a 3-4 ounce OC/pepper spray


A pilot with fewer staff carrying OC/pepper spray may be considered as an
alternative to everyone receiving it. Issuance to Sergeants or supervisors or
zones of control, and lone posts staff may be the first consideration.

We further recommend that the canister be of law enforcement strength formulation.
These canisters are sold by a number of vendors and utilized by numerous law
enforcement and corrections agencies across the country. While it is certainly true
that this additional tool provided to custody staff can be abused, the implementation
of careful control, supervision and accountability procedures and narrowly limited
parameters for its authorized use can serve to effectively mitigate these concerns to
only very rare instances. As with many decisions considered in the corrections field,
the questions to utilize the chemical agent or not becomes one involving a risk
assessment – does the risk of abuse/misuse by staff when appropriate controls are
put in place outweigh the benefits to be derived for the safety of staff and inmates?
We contend that it does.
Experience in jurisdictions where this tool has been put into place has been very
positive with instances of abusive use by staff occurring very rarely. Benefits in
terms of staff safety and reduction in staff and inmate physical injuries have also
been observed. The added initial concern that the chemical agent canister will be
taken from the staff by the inmates and used against them has also proved to be
unfounded except in the rarest of incidents. Lastly, the concern that staff will resort
to the use of the chemical agent before and instead of utilizing other non-force
options including providing verbal direction and employing verbal de-escalation
techniques has proven to be minimally problematic when standard use of force
requirements are stressed and careful reviews of each occurrence are conducted to
insure that parameters for use are not violated. These observations are not intended
to say that there will not be infrequent incidents of staff misuse of the chemical agent
just as there have historically always been such incidents involving hands-on
physical force by a very small percentage of our staffs. Accountability is a must in
either case and those staff who are abusive of the inmate population must be dealt
with sternly and when indicated removed from employment and held criminally
accountable when appropriate.
The use of the chemical agent canisters carried by staff on their person should be
clearly limited to spontaneous incidents where immediate response to an actual
assault or imminent threat of assault by an inmate(s) on themselves, another staff
member or an inmate is required and either there are no other viable options or all
other options have been exhausted. All other use of chemical agents including those
issued to each officer should continue to require prior approval of institutional
supervisory staff as currently prescribed.


It is recommended that a numbered seal be affixed to each chemical agent canister
carrier in such a manner that the canister cannot be removed from the carrier
without breaking the seal. All canisters in the carriers will be checked out at the
beginning of each shift and checked back in at the shifts end. The shift supervisor
should be charged with verifying the condition of the numbered seals and
periodically weighing random canisters to insure that they have not been used
without the required reports, etc. associated with the use of force.
It was noted during our visit to WSR that custody staffs currently receive training on
the use of chemical agents. The provisions for use of the canisters discussed above
should be included in this training. It should be strongly emphasized to staff that
abuse or misuse of these canisters will likely result in the loss of this valuable tool
being made available to them as a personal safety enhancement.

Training Enhancement
We did not note in the annual training curriculum for staff in the WSDC any specific
course designation for officer/staff safety. There were certain courses that included
various types of information on what officers/staff should do to insure their safety. As
we all know, prisons are inherently dangerous places where continuing vigilance and
an appropriate level of alertness are essential to everyone‟s safety. Despite this
knowledge, staff frequently becomes complacent and too comfortable in this volatile
environment. This fact results from the frequently routine nature of the day to day job
responsibilities and the fact that while volatility and potential violence always exist,
they exist beneath the surface and only become evident when, regrettably, it is often
too late. Frequent reinforcement by supervisors and managers of the existence of
this danger is imperative.

Recommendation 4
Consider as a part of efforts by managers to insure that staff are continually
reminded of the hazardous nature of work they have chosen, we recommend that a
training course be added to the annual mandatory training requirements that
addresses specifically officer/staff safety. This course should be approximately two
hours in duration and include real life scenarios to encourage discussion and
personal recognition of various situations from which concerns may arise. It should
also include refresher information on the use of all equipment and notification
systems associated with insuring staff safety. Examples of basic safety principles
that should be included, stressed and reinforced in the training are the following:



Never confront a confrontational, agitated inmate alone when it can be
avoided – in almost all cases time is on your side and the inmate is not
going anywhere – call for back-up.





Inmates respond better to redirection counseling, etc. when they are alone
and do not feel pressure to save face as with confronting them in the
presence of their peers.
Always insure that other staff know where you are within the facility
especially when you are away from your assigned area and that you are
fully aware of your surroundings to include all available means of egress
should you need to vacate the area quickly.
Ask yourself the “what if” question frequently as a means to assess any
situation and to have some plan for what you will do should a threat arise.
When responding to another staff member‟s call for assistance or any
other emergency situation always pause briefly/stage just outside the
incident area before entering the situation to assess it and if part of a
response team wait on other team members. A response team‟s
effectiveness is significantly lessened if they enter the incident individually.
Practice simulating the use of any emergency communication device or
equipment that may be available to you e.g. quickly locating the
emergency button on your two way radio or PBA.
Remember the “Three Truths of Officer Safety”:

Always expect the unexpected and have a plan! It can happen to
It is better to have mastered an officer safety skill that is never
needed than to need a skill that isn‟t mastered!

Although certainly not all inclusive, these examples should set the tenor for the
training and when combined with others along this same line and with Incident
Command System principles and facility specific information should result in a
compilation of information critical to staff survival in a prison environment.
Another way to emphasize the importance of the information contained in this
training is to issue each staff member a pocket handbook to which they can refer as
a refresher. The handbook should be a concise, abbreviated compilation of the
information provided in the training. Individual elements of information contained in
the handbook should be briefly referenced and discussed as necessary in roll call
periods to provide a daily reminder of the importance of the concepts included in it.
Upon your request, we will be willing to share staff safety curriculum developed in
our jurisdictions as well as an officer safety handbook developed along the lines of
that described above. We would only ask that you share with us anything that you
may develop so that we can learn from each other in this critical area.
Custody Staffing
We reviewed the custody staffing level at WSR in order to determine relative
sufficiency when compared to other jurisdictions with which we are familiar and to
determine any recommendations for re-distribution of this scarce resource. We
determined that there are 215 uniformed custody staff assigned to WSR. There is
some additional custody staff assigned to the Monroe Corrections Center complex

who provide support in various areas as needed but, for the purpose of this
assessment, only staff specifically assigned to WSR and the staff necessary to
provide relief for them for their regular days off, vacation, sick leave, etc. are
included. Considering that the current inmate capacity at WSR is 780 inmates, the
staff to inmate ratio for the facility is approximately 1:3.6.
This ratio is indicative of a very adequate, if not very good, custody staffing
allocation for WSR. In considering this ratio, it is important that we consider the
design features of this old facility and the fact that 28 of the 215 total custody staff
are assigned to various tower posts and, as such, are not available for direct
supervision and management of the inmate population in the facility. All of this
considered, it remains our belief that the institution is adequately staffed and no
additional positions are necessary. There are a couple of recommendations to follow
that could benefit the facility greatly and provide for enhanced safety and security
and improved operation.
Recommendation 5
Particularly problematic to maintaining adequate staffing on site and on post at all
times is the currently mandated 30 minute lunch break provided to all custody staff.
Considering that this break begins and ends at the facility entrance/exit point, it
frequently requires 45 minutes or more to actually complete and return to the
assigned post. Additionally, the hours of the shift during which the break has to
occur are also specified thus making the relief process all the more staff intensive
and operationally disruptive. These breaks result in critical areas such as the cell
blocks being posted at significantly reduced levels during high activity time periods.
The result is an “artificial” staffing shortage that is disruptive and problematic.
Discussions with custody staff at the WSR failed to produce anyone who was in
favor of these breaks; in fact, the disfavor harbored for these breaks was a common
thread vocalized in many of our interviews. We strongly recommend that this break
process be revisited and revised with the custody staff working a schedule
approximating the straight eight hour shifts previously utilized.
We further recommend that the operation of the numerous perimeter/wall towers be
carefully evaluated. It appears that several of these towers operate primarily in order
to operate and supervise gates located proximal to them. It may be that the staffing
associated with at least one if not two of these towers can be can be utilized
elsewhere at least on one or two shifts during which gate traffic can be disallowed.
The wall at the facility constitutes a formidable barrier that can only be successfully
breached with the aid of significant equipment items/tools/etc. and very inattentive
staff. There are a number of options in terms of sensors that can be utilized on the
wall to alert staff to any attempted breach. All of these considerations should be
examined to possibly allow for the redistribution of some of the positions currently
assigned to around the clock tower coverage to posts inside the facility with an
emphasis on enhancing internal post coverage
We would encourage a review of how all posts are deployed so the staffing is based
on peak activity areas and peak times of the day.

Single Officer Posts – Such posts are commonly found in all correctional jurisdictions
with which we are familiar. In addition to the other officer safety strategies discussed
in this report, the risks associated with such posts can be significantly mitigated by
enhancing the inmate accountability practices associated with them. For example,
inmates involved in any activity where security is provided by a single security officer
should be counted into the area (checked off an approved attendance/movement
list). This count should be conveyed to a control point such as tower 9 at WSR. At
the conclusion of the activity the inmate participants should be grouped together and
counted out prior to release back to the living area. Once released as a group, this
count should again be called in to tower 9 from where the inmates can again be
counted as they pass through the turnstiles already in place to facilitate this process.
This insures that all inmates have left the area and returned to the living area.
It is important to remember and to have procedures in place to account for the fact
that inmates in groups will almost never support individual, wanton violence by a
member of their population. Experience has shown that their presence serves as a
deterrent and that they will actually intervene themselves on behalf of a staff
member in such instances.
The predatory inmate plans for opportunities to get a staff member alone in an
isolated area. Preempting this opportunity is critical to the safety of officers assigned
to single person posts. Controlled and organized group movement procedures such
as that discussed are the key to mitigating the primary threat associated with these

Post Orders
We did review a number of post orders which relate to the Chapel post order, and
find there are discrepancies, and conflicting information in the Chapel post order.
It is apparent the post orders have been revised annually as required; however, this
is accomplished by one or two supervisory staff.
The revision may require inclusion of a team of custody staff to assist in determining
current practice, required practice, and conflicting information. It is difficult for one or
two staff to revise without custody staff seeing information which may not be
practiced or in effect any longer.
Examples of critical conflicting post order requirements and practice:

Chapel Officer P.O. states;
• “Daily, 2030 hours or when Chapel is secure, Report to the PAB, help officer
clear and secure building”. This has not occurred for a long time, if ever.


“Daily, 2100 End of Shift, notify Shift Sgt. that you are leaving, turn in all
equipment to control prior to leaving”. This was also not occurring.
These statements (requirements) are also not in the Shift Sgt. Post order nor the
PAB officers post order.


Recommendation 6
• Review and revise post orders to ensure clear, concise directives and
• Assure supervisors know and understand their subordinate‟s responsibilities
and post order requirements.
• Assure supervisors are accountable for follow up and enforcement of post
orders, and accomplish on the job training with staff at their posts on a
frequent basis to mitigate complacency.
• Consider developing and implementing a supervisor handbook.
Inmate Movement/Call-outs/Passes
Inmate clerks in Chapel and Prison Activities Building (PAB) manage
communications (kites) from inmates to access areas and programs, and screen
communications (kites) to determine inmate eligibility for program; then place
inmates on call-outs, (Offender Attendance Roster) for the programs.
The call-outs then get posted in housing units to alert the inmates if they are
authorized to attend program.
The inmate clerks then make another list for the Chapel Officer called the Offender
Attendance Roster (different format than unit rosters). When comparing the roster for
the staff, and the one for the unit inmates, we discovered numerous discrepancies.
The staff attendance roster authorizes more inmates than are on the call-out roster
posted in the housing units, and the inmate call-out contains some inmates not listed
on the staff attendance roster. The staff use the one created for them; and many
inmates came to chapel that evening that were not on the roster posted in units.
All these documents were created by an inmate clerk with no check by staff. Staff
responsible for checking these documents stated that there was no time in the day
to check all the work the clerk did.
There is no accountability on either end of the process for inmate movement.
The inmate clerks should never be involved in this process as it would be too easy to
manipulate inmates authorized to go to an area for illegal or unauthorized activity.
Though this did not have a direct impact on what occurred that evening; however,
the system is flawed.
Inmate movement also occurs on a call-out basis through Offender Management
Network Information (OMNI). This is a new system, and has not had the bugs

worked out to accommodate programs and activities. OMNI appears to cut the work
load for staff when it comes to work assignments, but does not have the capability to
manage a program that changes frequently. Manual input is required for the
numerous daily changes for program and activity attendance. Upon discussion with
staff who manage the OMNI call-out system, and other staff working within the
MCC/WSR compound, it is clear the system is not accurate all the time, and the
process still confusing.
The OMNI system can have one inmate scheduled for four different programs for the
same time on the same day.
There is also great confusion among all staff on how the change in the call-out
process is supposed to occur especially within the recent days while the inmates are
coming off full lock-down.
The pass system is not workable, and does not account for inmates leaving and
returning to units. The staff in housing units create a pass for an inmate;
there is no carbon copy or log of the pass created, so if an inmate does not return to
unit, and they find the inmate missing they have no point of reference of where the
inmate was sent. This is an ineffective system at best.
Recommendation 7
The entire movement system for inmates for all work, activities program, passes
should be reviewed, and a new system considered.
Inmate movement is a system which should be one of credibility and protects the
integrity of safety within every facility.
We would also recommend a review of movement and call-outs in all WA facilities to
assure whatever the process is used; it is as consistent as possible.
Consider a team of staff to be on a planning committee so custody staff and other
department staff can add value to how the movement process works based on the
fact that they are closest to the process. The practice of accounting for inmates is
their responsibility on the ground working with the inmates.
If the system has no integrity, human nature is do what you believe is appropriate.
This leads to complacency and vulnerability within the process.
Camera Placement and Visibility
We discovered upon reviewing the schematic of chapel locations, there are no
cameras in the Chapel proper. There are cameras in corridors, and facing offices.
We recognize that technology is only as good as the staff that have the ability to
monitor and observe those cameras; however, we also know that there is not
enough staff to monitor all the cameras throughout a facility.

The monitors are all recorded at MCC, so if there is a camera, they can be used for
investigating purposes. The monitors throughout MCC are of good quality and
monitors were working during our visit.
The Industries area has cameras but the location of existing cameras was either
nonexistent or were directed towards stationary material and not staff or inmate
movement visibility.
Recommendation 8
There is a need for more cameras, redirections of lens, or relocation of them. We will
discuss in the recommendation section immediately after this observation.
While we recognize budget cannot possibly allow for all cameras in all places; relocation and placement can make a huge difference.
As a matter of fact, the staff was working on relocation, and direction of cameras in
the industries area the day after we spoke to them regarding this issue.
Recently there was a schematic of camera needs for MCC accomplished by
maintenance staff; however, we recommend you consider using security staff and an
electronics person to determine the location, placement, and direction of cameras to
achieve the most appropriate, and effective coverage within the facility. The
prioritization of new cameras should subsequently be based on high risk, limited
staff supervision and budget considerations.
It may be noted that Prison Rape Elimination Act (PREA) also should be considered
when identifying placement and camera needs.
Inmate Volunteers
Inmate Scherf was an inmate volunteer clerk for the Chapel. On the day of the
incident he was on call-out for the Full Gospel program, yet according to the
Chaplain he was in the clerk‟s office with Inmate Lindermood assisting him with a
new call-out process.
The Chaplain did not know how he came to be a volunteer clerk. He thought
perhaps he had been assigned or used as clerk by the previous Chaplain so
continued the practice as routine. The Chaplain thought there may be a list in his
office from the prior Chaplain but there is no access to the area since it is still a
crime scene.
There are times when we all assume something is authorized and sanctioned, and it
is not.
There is no policy or protocol written that relates to authorization for inmates to be
“volunteer clerks”. There is no screening process, or boundaries for inmates in this
capacity to follow.


The paid inmate clerk for PAB has been working there for 40 years. There is a
danger of crossing boundaries with inmates who are a position for such long periods
of time because staff tend to have too much trust in them. Inmate clerks are relied
on to complete tasks and do things we do not have time for. Staff refer to this
particular inmate as “the go to guy”.
No inmate should be allowed to gain this much power in the correctional
environment. This usually means we have no idea what they are doing on the
computer or if they are manipulating the system. This leaves vulnerable to
unauthorized or illegal activity by inmates.
Recommendation 9
It would be beneficial to review all inmates who have a capability to become an
inmate volunteer clerk, and consider not having inmate clerks as volunteers unless a
system is designed to accommodate such a practice.
We recommend you consider a time limit for inmates in work assignments to
mitigate their power, and balance the boundaries so to speak.
Industries, back complex inmate access (Gate 7, security checkpoint) for jobs,
programs, and movement
The process for determining eligibility for inmate work assignments is accomplished
through the Correctional Program Manager (CPM), and Investigation unit based on
limited criteria: that being; infraction time span, classification, gang affiliation, and
inmate conflict potential in the work area.
This review does NOT include inmates assigned to horticulture or anything other
than work assignments in the area behind Gate 7, security checkpoint.
Gate 7 is not a magic end all for determining inmate access; there is the chapel, and
other areas which are isolated for staff and volunteers (not behind Gate 7
checkpoint) where a criteria and more personal safety systems should be build into
the system.
Recommendation 10
Consider reviewing criteria for life without parole inmates to work various areas, and
what activities are necessary in high security areas.
Create a multi-disciplinary team to develop criteria and review LWOP, and
dangerous inmates for any job or access to critical locations in the compound;
especially if the areas are supervised by one staff or person. The multi-disciplinary
team could consist of Security Staff, Counselor, Associate Superintendent, CPM and
Investigator. The team should be balanced and have criteria other than infraction
history, gang affiliation and conflicts.


If this is a difficult to manage process or the inmates would be unnecessarily limited
freedom to accomplish programming necessary for their living environment, then
consider placement in a facility that can accommodate those who require more
freedom with necessary security precautions.
Visibility/ Safety
Tower 9 visibility is somewhat limited even with the camera system. There is a
building immediately to the side of the Chapel not used for staff, programs or any
activity at this time.
Industries areas have some limited visibility.
Recommendation 11
Consider removing that building to allow for a wider view of horticulture and other
areas beyond Gate 7.
Continue the process of evaluating the cameras, monitors, and recording devices in
the entire industries areas.
Security Audit
There are areas with tools, keys, computer use by inmates, and numerous other
security systems which may not be as compliant as needed.
Recommendation 12
There are other security system issues which may benefit from an outside security
audit for not only WSR but the other MCC complexes as well.
Current Change Process
Instructional Memorandums have gone out regarding operational change in
movement and schedule for inmates, training on radio system acquisition and
Follow through on change directives have been lacking by supervisors. Non-custody
staff had never been told they would be trained on radio and alarms. This was told to
us on 3-2-11, and the memo stated they would be trained by 3-1-11. Custody staff
not involved in musters did not know of the training. It may be that they did not read
the e-mail sent to staff; however, a better tracking system should be in place.
Operational Updates are e-mailed to staff as they come out. While these are
comprehensive updates, it appears staff is very confused in many areas about how
operations have changed and specifically going to occur.
It is possible that some staff do not read them because of volume or recognize the
importance of the document, or cannot translate how the directions apply to their
position responsibilities.

Recommendation 13
While confusion is quite normal during this type of change, especially when all staff
are trying to heal and recover from this tragic incident, communication and follow up
by supervisors and management is imperative. The paperwork and processes
sometimes get in the way of what we need to accomplish.
This would be the perfect opportunity to lighten the supervisors‟ paperwork and allow
management by walk around (MBWA) to field staff questions, train and support them
as they manage their routine duties and help make those operational changes
It does appear the supervisors are spending much time in office rather than being
out and on posts throughout facility. Follow-through, monitoring, and staff support
should be a priority, especially at this time.
Classification Review – Inmate Scherf
Summary of Offenses
04-10-1978 - Assault 2nd Degree
05-05-1981 - Rape 1st Degree, Assault 1st Degree
10-06-1995 - Rape 1st Degree, Kidnapping 1st Degree, Unlawful Possession
Abbreviated Classification Chronology:
06-19-97 Initial Classification
Close Custody Designated
09-30-97 Classification Referral/Administrative Segregation
Inmate Scherf requested protective custody on 09-09-97 based on alleged threats.
Committee decided that there was not any verified need for protection. Comment
made in risk assessment: “Inmate has demonstrated that he will manipulate staff to
get what he wants”. Return to G/P
06-12-01 Classification Referral Annual
Information indicates that Inmate Scherf had been admitted to Administrative
Segregation at MCC-SOU (Sex Offender Unit) after a “serious suicide attempt
wherein he ingested 90 Tylenol tablets. He was determined to be stable and
indication of a multidisciplinary mental health evaluation was noted for completion by
July 200l. Decision to transfer to WSR, change custody from close to medium with
LWOP override.
2001 Comprehensive (Multi-Disciplinary) Mental Health Report

Referral History Completed on 06-07-01
Included section (page 10 of 20) Alerts to Correctional Staff
“Inmate. Scherf has indicated previously that he would have problems with women
supervising him while on parole supervision.” It is likely that this sort of difficulty
would also present toward women in authority within the prison system.
Classification Policy WDOC 300.380 Effective Date 5-8-02
Section II E page 4,
“Any time there is new information regarding any of the categories in the CHS
(Criminal History Summary), or ICD (Initial Custody Designation) scoring factors, or
for offenders who have more than 4 years left to serve at the time of initial
classification, the assigned counselor/staff will conduct an immediate review to
determine if this information results in a change in custody level designation”.
Inmate Scherf transferred to WSR
07-26-01 Risk Management Identification Form Initial Assessment
Sex Offender Level III. Should be considered as such
In section titled, Override
Recommendation: No
Rationale: Inmate(P) is an LWOP case. P has a history of repeated sexual violence
that has included threats to the lives of three women. P has serious issues with
women and has stated that there would be problems with supervision by female

Classification Policy DOC 300.380 Effective date 5-8-02
Section VI G page 12
The Department will make discretionary decisions regarding the placement and
movement of offenders regarding the placement and movement of offenders to
lower levels based on the outcome of risk assessments and evaluations for
offenders convicted of offenses that can be registered.
Annual Facility Plans, and Classification Referrals were reviewed and it was noted
that some were held in absentia, and recommendations were not consistently
recorded and/or filed in master file, and were not filed in the master file, some were
electronically stored.
When inmates are transferred to MSR, one on one interviews are conducted with the
assigned counselor.
Psychological Reports are not a part of the one on one counseling. Facility Risk
Management Team (FRMT) reviews was scheduled consistent with one year Initial
classification review.


The Classification and Custody Facility Plan Review Policy DOC 300.380, Revision
date 8-04-08 is more definitive and explanatory in directing classification procedures
and establishes measurable controls for staff compliance.
“Sound corrections programs at all levels of government require a careful balance of
community and institutional services that provide a range of effective, humane, and
safe options for handling adult offenders. Corrections must provide classification
systems for determining placement, degree of supervision, and programming that
afford differential controls and services for adult offenders, thus maximizing
opportunity for the largest number”.
The Classification process is the system upon which corrections professionals rely
upon to evaluate inmates to determine what their needs are, where they can best be
appropriately met, assignment of security and custody levels, risk assessments
while meeting the requirement to provide public safety. In ensuring that these areas
are addressed, a system of supervisory oversight is necessary to monitor staff
compliance with directives. The Classification process is designed to be objective
but by no means a perfect science.

Recommendation 14
• The review of all LWOPs will prove to be a vital process to enhance overall
security of the facility. The aforementioned classification documents, if
reviewed and considered in the classification referral process, or establishing
different criteria for access within the facility with specific criteria above and
beyond the classification process, may have more appropriately managed
Inmate Scherf‟s supervision level. Consider an enhanced process for inmate
access to areas within the compound, and possibly other facilities.


Validate and combine electronic Inmate Files with hard copy.


Review all 137 LWOPs using current Classification Policy with added criteria
based on hard file risk assessment criteria or revised criteria for work and
activity access.

Staff Accountability
Correctional agencies have the responsibility to operate safe and secure
facilities to ensure optimum public safety, safety of staff, contractors,
volunteers and visitors who frequent their facilities. It is critical to have
accurate accountability for all staff within for daily operations as well as
emergency situations.
There currently exists at the Washington State Reformatory (WSR) musters for the
day, swing, and graveyard shifts where oncoming staff are accounted for


There is no muster or centralized accounting system for staff assigned to different
shifts nor non-custodial staff.
Recommendation 15
• Development of system and policy to accurately account for all staff,
contractors and volunteers.


Ensure that policies are disseminated, training conducted, and monitored for

Staff Comments
The comments noted made by staff are not all inclusive; however, there may be
validity to many of the comments. Some staff preferred not to identify themselves
but had comments. No staff displayed resentment while discussing issues with us,
they appeared more frustrated than anything. This is also to be expected after an
incident such Officer Biendl‟s death. You may note that some of the issues and
concerns have been addressed through our review during the week.
Staff comments based on what they thought may be some security issues or



Consider using the ID barcode to track and account for staff while inside the
Design an accountability process to know staff whereabouts to include all
non-custody staff.
Budget more staff so the units are not left with one officer during main line
and peak hours of activity, especially since that is when a lot of staff are out
for an hour for meals.
Remove the glass plates from the microwaves in the units.
Stop using inmates to repair cameras for yard and have staff doing this task.
Do not pressure staff to join a joint inmate/staff choir.
Stop using staff to water plants in the horticulture area. Inmates should be
doing this.
We need more cameras to detect what is going on in single posts and areas
of limited visibility. Structure inmates daily activities. Too much movement too
Line custody staff is not briefed on rules and policies that change. Make more
time for us to understand.
Some staff pencil whip logs and forms of importance, complacency.
Tower 9 computer and monitors go down in the summer when hot, no cooling
system installed.
Inmates know operational changes before we do.
Industries supervisors have to be in office up to 6 hours a day, that at
numerous times has meant no one supervising the work in shops unless the
custody officer makes the hourly check.


The mattress factory behind industries building has trucks come in and park
and no one is checking them or logs the driver in and out.
Another count during the day instead of just start of shift would enable us to
know if all inmates are accounted for.
We don‟t see the Captain or Lieutenants often enough.
The Tab shop has three keys for area, if two of the staff is not there and the
TAB Shop supervisor needs to get out he cannot. Consider doing something
for safety reasons.
Female industries staff are concerned with cameras and being alone with
numerous inmates and the inability to leave office often enough to supervise.
Searches of industries area are “catch as you can”. Never time to do this area
in sufficient manner.
The PAB can have as many as 102 volunteers and inmates at one time with
up to 80 in one room. The rooms have not been capacity rated and we would
like to see that happen.
Housing Unit cell searches are supposed to be once every two months;
however, this does not occur because of staffing shortages.
Training is inadequate because they do not accomplish what they should in
defensive tactics because they have too many injuries.
Radio identification for staff is off in the numbering system, they need to
correct that.
Shift Sergeant, Lieutenants, and Captains need to get on same sheet of
music. Some want policies followed to the letter, others want us to be flexible,
but no one really know which ones are to be taken literally.

We wish to thank all staff for the open dialogue and discussion with us. We truly
experienced hospitality form all we met within the Washington Department of

End of Report