State of New York Office of the Inspector General Investigation of the June 5, 2015 Escape of Inmates David Sweat and Richard Matt from Clinton Correctional Facility June 2016 Catherine Leahy Scott Inspector General STAFF FOR THIS INVESTIGATION AND REPORT SPENCER FREEDMAN Executive Deputy Inspector General JAMES CARROLL Deputy Chief Investigator (Downstate Region) ELEANORE RUSSOMANNO Investigative Auditor (Upstate Region) MICHELE HOST Chief Counsel DENNIS GRAVES Supervising Investigative Auditor (Upstate Region) JASON FAZIO Investigator (Upstate Region) FRANK RISLER Chief Investigator Digital Forensics Lab ROBERTO SANTANA Investigator (Downstate Region) PETER AMOROSA Investigative Auditor (Upstate Region) JOSHUA WAITE Senior Investigator (Upstate Region) JOHN MILGRIM Special Deputy for Communications ROBERT PAYNE Investigator (Upstate Region) JEFFREY HAGEN Deputy Inspector General (Western Region) GARY WATERS Investigator (Upstate Region) STEPHEN DEL GIACCO Director of Investigative Reporting (Upstate Region) STEPHANIE WORETH Investigator (Upstate Region) JAMES R. DAVIS Deputy Inspector General (Upstate) BERNARD S. COSENZA Deputy Inspector General of Investigations SHERRY AMAREL Chief Investigator (Upstate Region) JAMES L. BREEN Investigative Counsel (Upstate) DANIEL WALSH Deputy Chief Investigator (Upstate Region) ERIN BACH–LLOYD Investigator (Upstate Region) ANA PENN Investigator (Upstate Region) JEFFERY HABER Investigator (Upstate Region) JOHN JURS Investigator (Upstate Region) AMY T. TRIDGELL Director of Investigative Reporting (Downstate Region) JONATHAN MASTERS Director of Investigative Reporting and Special Counsel KATHERINE GEARY Special Assistant (Upstate Region) KELLY YATES Special Assistant (Upstate Region) Table of Contents EXECUTIVE SUMMARY .......................................................................................................................... 1 Introduction ............................................................................................................................................... 1 The Causes of the June 5, 2015 Escape .................................................................................................... 2 Summary of Recommendations of the Inspector General ........................................................................ 9 Methodology of the Inspector General’s Investigation ........................................................................... 10 BACKGROUND ........................................................................................................................................ 12 Clinton Correctional Facility .................................................................................................................. 12 The Department of Corrections and Community Supervision ................................................................ 12 DOCCS’s Division of Industries at Clinton ............................................................................................ 13 THE PLANNING AND EXECUTION OF THE ESCAPE OF SWEAT AND MATT ............................ 14 Preliminary Note ..................................................................................................................................... 14 David Sweat and Richard Matt ............................................................................................................... 14 Sweat and Matt Fired From and Regain Prison Tailor Shop Jobs .......................................................... 16 Housing in Honor Block ......................................................................................................................... 18 Joyce Mitchell’s Improper Conduct in Tailor Shop 1 ............................................................................. 20 Matt and Sweat Manipulate Correction Officer Eugene Palmer and Others .......................................... 23 Sweat Removed from Tailor Shop 1 ....................................................................................................... 26 Matt Cultivates a Relationship with Joyce Mitchell ............................................................................... 30 The Decision to Escape and the First Tools Smuggled by Mitchell ....................................................... 34 Mitchell’s First Delivery of Hacksaw Blades ......................................................................................... 38 Sweat and Matt Cut Through Their Cell Walls ...................................................................................... 39 Holes in Cell Walls Go Undetected ........................................................................................................ 41 Sweat Begins Search for Escape Route Under Prison ............................................................................ 46 Breaching the Brick Wall........................................................................................................................ 50 Sweat Reaches the Inside of the Prison’s Main Wall ............................................................................. 52 Mitchell Smuggles in More Tools and Joins Plan to Leave with Matt and Sweat ................................. 58 Mitchell and Matt Have Sexual Encounters in the Shop ........................................................................ 60 Mitchell and Matt Discuss Murdering Mitchell’s Husband .................................................................... 64 Matt Seeks Mitchell’s Help in Retrieving a Package from Outside the Prison ...................................... 66 Sweat Cuts into the Steam Pipe .............................................................................................................. 68 Sweat Breaches the Prison’s Main Wall and Conducts Test Run of Escape .......................................... 72 Two Incidents Imperil Escape Plan ........................................................................................................ 75 Sweat’s and Matt’s Final Preparations.................................................................................................... 77 The Escape, Then an Encounter on the Street ........................................................................................ 79 Mitchell Goes to the Hospital with a “Panic Attack” ............................................................................. 82 Sweat’s and Matt’s Empty Cells Discovered .......................................................................................... 82 Mitchell, Palmer, and Sweat Are Charged with Criminal Acts .............................................................. 84 ANALYSIS OF FACTORS IN THE ESCAPE OF SWEAT AND MATT ............................................... 87 Failure to Properly Search Employee Bags at the Front Gate ................................................................ 88 Night Counts of Inmates ......................................................................................................................... 92 Cell Searches......................................................................................................................................... 102 Cell/Razor and Catwalk Inspections to Ensure Cell Integrity .............................................................. 108 Tunnel Inspections ................................................................................................................................ 109 Tool Control .......................................................................................................................................... 110 Metal Detectors ..................................................................................................................................... 111 Utility Markings on Industry Building Wall ......................................................................................... 112 Ineffective Supervision and Mismanagement in the Tailor Shops ....................................................... 113 DOCCS and Clinton Management Oversight of Clinton Security ....................................................... 123 The May 31, 2015 Inmate Melee and Request for a Lockdown ........................................................... 127 OSI’s Investigations of Mitchell’s January 2015 Complaint ................................................................ 130 The 2003 Escape of Two Convicted Murderers from Elmira Correctional Facility ............................. 133 Deficiencies in DOCCS Training of Security and Civilian Staff.......................................................... 137 FINDINGS AND RECOMMENDATIONS OF THE INSPECTOR GENERAL.................................... 140 Oversight of DOCCS is Required to Ensure the Integrity of the System ............................................. 140 Front Gate Security ............................................................................................................................... 141 Night Shift Counts ................................................................................................................................ 142 Cell Searches......................................................................................................................................... 144 Tunnel Security and Inspections ........................................................................................................... 145 Catwalks................................................................................................................................................ 145 Metal Detectors ..................................................................................................................................... 146 Contractor Training and Tool Control .................................................................................................. 146 Tailor Shops .......................................................................................................................................... 147 Honor and General Housing ................................................................................................................. 148 Internal Controls ................................................................................................................................... 149 Security and Civilian Staff Training ..................................................................................................... 149 Discipline and Counseling .................................................................................................................... 150 EXECUTIVE SUMMARY Introduction Shortly after 11 p.m. on Friday, June 5, 2015, convicted murderers David Sweat and Richard Matt slipped through holes they had cut in the back walls of their cells in the Honor Block at Clinton Correctional Facility, a maximum-security prison operated by the New York State Department of Corrections and Community Supervision (DOCCS). Using pipes as handand foot-holds, Sweat and Matt descended three tiers through a narrow space behind their cells to the prison’s subterranean level. There they navigated a labyrinth of dimly lit tunnels and squeezed through a series of openings in walls and a steam pipe along a route they had prepared over the previous three months. When, at midnight, they emerged from a manhole onto a Village of Dannemora street a block outside the prison wall, Sweat and Matt had accomplished a remarkable feat: the first escape from the high-security section of Clinton in more than 100 years. A correction officer conducting the morning count discovered Sweat’s and Matt’s empty cells at 5:17 a.m. on Saturday, June 6. An hour later, after the entire prison had been searched, they were declared missing. A manhunt was launched by the New York State Police involving, at times, more than 1,300 officers from local, state, federal, and Canadian law enforcement agencies. A U.S. Customs and Border Protection officer fatally shot Matt, who was armed, in the Town of Malone on June 26, 2015. Sweat was apprehended on June 28, 2015 when, after failing to comply with an order to halt, he was shot and wounded by a State Police sergeant in the Town of Constable. The escape and three-week manhunt disrupted and brought fear to communities and residents throughout the region. The search for Sweat and Matt cost New York State approximately $23 million in state law enforcement overtime. The costs incurred by federal and local agencies, as well as other states and countries, are not included in this total. New York State spent an additional $573,000 on repairs to the prison and additional security measures. On June 15, while the search for Sweat and Matt was ongoing, Governor Andrew M. Cuomo directed Inspector General Catherine Leahy Scott “to conduct a thorough investigation to determine all factors potentially involved in the escape” and “recommend any potential reforms and best practices to prevent future incidents.” The Inspector General undertook this task and conducted a thorough investigation, independent of inquiries by any other entity or agency. The 1 investigation found that longstanding, systemic failures in management and oversight by DOCCS enabled two convicted murderers to meticulously orchestrate their escape from a maximum security facility. In addition, security and management failures at Clinton created and perpetuated a culture of complacency and revealed a substantial deviation from acceptable correctional practices. During the pendency of the investigation, DOCCS has cooperated with the Inspector General and has implemented many of the recommended corrective measures. The Inspector General’s investigation identified a number of DOCCS employees who committed criminal acts and violated DOCCS directives and policies. The Inspector General has referred these matters to the Clinton County District Attorney’s Office, the New York State Joint Commission on Public Ethics, and DOCCS for appropriate action. DOCCS has taken and will continue to pursue affirmative steps to appropriately discipline employees implicated in the Inspector General’s investigation. Many of these employees have resigned or have been terminated. Additionally, DOCCS has been cooperating with the American Correctional Association, which is assessing New York State’s prison operations to ensure compliance with national standards. The Inspector General is providing the results of this investigation to the Association to assist with its endeavors. The results of the Inspector General’s comprehensive investigation, which was conducted pursuant to Article 4-A of the Executive Law, are described in this report. The Causes of the June 5, 2015 Escape The June 5 escape from Clinton was planned and executed by two particularly cunning and resourceful inmates, abetted by the willful, criminal conduct of a civilian employee of the prison’s tailor shops and assisted by the reckless actions of a veteran correction officer. The escape could not have occurred, however, except for longstanding breakdowns in basic security functions at Clinton and DOCCS executive management’s failure to identify and correct these deficiencies. Sweat and Matt began plotting their escape in January 2015 and immediately enlisted the help of Joyce Mitchell, the civilian supervisor in Tailor Shop 1, where Sweat had worked previously and where Matt was still employed. For less than $6, Mitchell purchased six hacksaw blades that she was able to smuggle into the prison because officers at the front gate, contrary to policy, failed to search her bag. Later that day in the tailor shop, Mitchell handed the blades to Matt, who carried them to his cell taped to his side under his shirt. Matt’s actions went 2 undetected because he returned to his cell that day under the escort of a correction officer, almost certainly Eugene Palmer, whose trust he had gained over the years. Palmer conceded that his practice was not to frisk inmates under escort from the shop, nor did he require that they pass through a metal detector on the return to their housing blocks. Sweat and Matt, who, also with Palmer’s assistance, were housed in adjacent cells on the third floor of the Honor Block, then toiled daily for almost three weeks to cut holes in the rear walls of their cells, working while other inmates were at recreation. Over the next three months, Sweat left his cell nearly every night. First placing a dummy in his bed, he climbed down three levels of catwalks to search for an escape route through the dark, confusing network of tunnels below the prison. Sweat was temporarily stymied by three formidable obstacles: a narrow pipe chase connecting two cell blocks, a multi-layered brick wall, and the seven-foot thick base of the perimeter wall. He was able to get past the obstacles using additional tools provided by Mitchell. On two occasions, Mitchell hid escape tools in frozen ground beef that she smuggled into the prison. These tools included two chisels, a steel punch, two concrete drill bits, and two additional hacksaw blades. At Mitchell’s request, Palmer carried the tool-laden meat from the tailor shop to Matt’s cell. Even if unaware of what the meat contained, Palmer knew the meat alone was contraband, and that he was committing a crime and violating prison rules by transporting it. Sweat also used tools he removed from a contractor’s locked storage box that he picked open, and others he fashioned from pieces of discarded scrap metal he happened upon in the tunnels. From the time they first breached the rear walls of their cells to the date of the escape, security staff conducted at least 15 weekly scheduled cell inspections and one unannounced cell search. However, the inspection and search were hasty and superficial, and failed to detect the holes. Sweat’s almost nightly and hours-long absences from his cell went undetected because security officers either failed to conduct required hourly rounds or did so negligently. Just one properly performed night round during this months-long period would have foiled the escape. Further, tunnel inspections, which might have discovered Sweat’s handiwork below the prison, were rarely performed. The prison’s main wall posed the greatest physical obstacle to the escape. After laboriously chipping away with a hammer, chisels, and a steel punch at the wall for many nights, but making scant progress, Sweat benefited from an unexpected event – in early May the 3 prison’s steam generating plant shut down the prison’s heating system for the season. Then, using hacksaw blades, Sweat cut entry and exit holes in the now cooled, 18-inch-diameter steam pipe that passed through the main wall, gaining access to a tunnel connecting the prison to the steam plant on the morning of June 5. Following that tunnel, Sweat came upon a manhole cover secured with a chain and lock. After cutting the chain and lifting the cover just enough to confirm his location on a village street, Sweat hastened back to his cell and advised Matt that the escape route was complete. Just past 11 that night, after having worked a final shift in the tailor shops, Sweat and Matt made their getaway undetected by correction officers. Although he contributed little to the actual work in the tunnels, accompanying Sweat below on only two occasions prior to the night of the escape, Matt played an essential role in the plot by nurturing his and Sweat’s relationship with Mitchell. This relationship resulted in Mitchell agreeing to smuggle tools into the prison and taking other actions in furtherance of the escape. In addition, Matt gained the trust of Palmer, who facilitated the delivery of escape tools to Matt and Sweat. Over the years, Matt curried favor with Palmer by giving him numerous paintings and drawings he produced in his cell. Matt also purportedly possessed personal connections in Mexico, where he and Sweat hoped ultimately to find a haven. The deceit and ingenuity of Sweat and Matt notwithstanding, the escape was possible only with the brazen assistance of Mitchell. As early as mid-2014, Mitchell developed personal relationships with both inmates in the tailor shop she supervised. Over the next several months, Mitchell performed improper favors for Sweat and Matt, including sharing food with them in the shop, calling Matt’s daughter on his behalf, and smuggling into the prison numerous personal items for them. Mitchell was confident her smuggling of contraband, including escape tools, would succeed because she knew security staff at the prison’s front gate did not conduct required checks of employees’ bags. Moreover, Mitchell’s numerous acts of misconduct in the tailor shop occurred in the presence of a negligent correction officer, Allan Trombley. According to staff and inmates alike, Trombley routinely failed to perform his duties, instead spending much of the day reading at his desk. In early 2015, the relationships deepened and Mitchell became an even more active participant in the escape plot, ultimately agreeing to join Sweat and Matt after their breakout and drive away with them. In addition to smuggling escape tools and maps, Mitchell agreed to be a conduit to obtain cash for Matt and gathered items to assist their flight, including guns and 4 ammunition, camping gear, clothing, and a compass. Even as she professed her love for Sweat in notes she secretly sent him, Mitchell engaged in numerous sexual encounters with Matt in the tailor shop. These included kissing, genital fondling, and oral sex. Mitchell, according to Sweat, also schemed with Matt to murder her husband, and in fact took steps to accomplish this plan. Among other actions, Mitchell accepted from Matt several narcotic painkiller pills he had been prescribed by prison medical staff. Mitchell said she intended to surreptitiously administer the drugs to her husband to “knock him out” prior to her leaving the house to pick up the escapees. However, on the night of the escape, Mitchell failed to drive to the agreed-on rendezvous point and left Sweat and Matt to flee on their own on foot. The actions of Sweat, Matt, Mitchell, and Palmer, however, do not fully account for the events of June 5. The escape occurred in a prison where lapses in basic security functions were longstanding. These included the failure by officers assigned to the front gate to search employees’ bags entering the prison; night counts of inmates that were conducted negligently or not at all; inadequate cell searches; and poor supervision of inmates and employees by security staff and civilian managers in the tailor shop, among others. In addition, oversight of Clinton’s security operations by Clinton management and DOCCS was inadequate. Significantly, the many failures revealed by the Inspector General’s investigation did not arise only as Sweat and Matt planned and executed their escape. Indeed, they are of long duration and reflect a complacency regarding security at Clinton that is alarming and unacceptable. One DOCCS executive testified that basic security practices at Clinton were characterized by a “culture of carelessness.” The Inspector General is incredulous that highranking security staff, including executive management officials, were unaware of these deficient practices. The specific security and management oversight failures that contributed to the June 5 escape at Clinton are summarized below: Front Gate Searches Front gate officers failed to adequately screen employees entering and leaving the prison. Despite explicit language in policy and written reminders from DOCCS central office, officers did not search the bags of security or civilian staff. In addition, although officers have the authority to require employees to pass through a metal detector located at the front gate, in 5 practice this never occurs. Compliance with search requirements and random utilization of the metal detector might well have deterred or caught Mitchell’s smuggling of hacksaw blades and other escape tools into the prison. Night Counts Policy requires officers to conduct counts of inmates throughout the night to ensure they are present in their cells. The investigation determined that counts were grossly inadequate or, in many instances, almost certainly not conducted at all. Over the course of approximately 85 nights that Sweat was working in the tunnels, more than 400 inmate checks should have occurred, any one of which, if conducted properly, would have detected Sweat’s absence and instantly foiled the escape plot. In addition, the investigation found that officers in the Honor Block and other housing units improperly complete count slips in advance of scheduled counts. There are no cameras in place to monitor night counts in any housing block except the Special Housing Unit. Cell Searches Clinton’s program of unannounced cell searches, essential to controlling inmate contraband, was deeply flawed. Indeed, within the year preceding the escape, multiple cells were never searched, including Sweat’s cell. Although a computer produced a random list of cells for search each day, security staff selected one cell from the list that would actually be searched, thereby injecting discretion and possible bias into a process intended to be objective. Moreover, cell searches were hasty and cursory, and failed to find any contraband 96 percent of the time. In fact, a documented search of Matt’s cell on March 21, 2015 failed to detect the 18½inch-by-14½-inch hole in the rear wall of cell that is only approximately 48 square feet. A proper cell search would have found the breach and thwarted the escape. Security and Civilian Supervision in the Tailor Shop Mitchell’s improper interactions with inmates in the tailor shop were long known to her civilian supervisors and observed by correction officers assigned to ensure security in the shop, yet no effective action was taken. In Tailor Shop 1, where Mitchell worked from November 2013 to the day of the escape, a permissive environment existed in which rules governing staffinmate interaction were not enforced. Mitchell’s improper actions resulted in her developing close personal relationships with Sweat and Matt, leading to her decision to abet them in their 6 escape plan. Equally troubling, Mitchell’s many criminal acts, including smuggling escape tools and repeated sexual contact with Matt, went unnoticed by the correction officer assigned to the shop. Other Security Lapses The Inspector General’s investigation revealed deficiencies in other facets of Clinton security, as follows: ● Inspections of Clinton’s tunnels, which purportedly had been frequent and thorough in the past, were de-emphasized in or around 1995. A plan developed in 2014 to begin “quarterly” tunnel inspections, alternating between the main and annex sections of the prison, was not fully implemented. As a result, a single tunnel inspection of the main prison occurred, in September 2014, and none was conducted prior to the escape in 2015. Had the plan been executed as intended, a main prison tunnel inspection would have been conducted in March 2015 and might well have detected the escape plan. ● Officers failed to properly conduct at least 15 required weekly inspections of “cell integrity” to include examination of “bars, floors, vents, walls, and rear of cell from the catwalks.” In fact, many officers testified they were not even aware of these required checks. These inspections, if performed as required, would have revealed the breaches in the walls of Sweat’s and Matt’s cells. ● While Clinton operates six metal detectors at various locations to prevent the movement of contraband, gaps in their utilization occur. A critical lapse almost certainly occurred in February 2015, when Matt, in the company of an escort officer, smuggled six hacksaw blades taped to his body from the tailor shop to his cell, by-passing the metal detector on his route. In fact, single inmates under escort are rarely required to pass through a metal detector; nor are single inmates escorted from the tailor shops regularly subjected to body frisks. ● Tools were left unsecured in the tunnels, in violation of policy. An unsecured sledge hammer and extension cord were used by Sweat in his escape efforts for over a month and never returned. In a further violation, a contractor failed to report a missing steel punch that Sweat had taken from a “gang box” in a tunnel and never returned. 7 Oversight Failures by Clinton Management and DOCCS Monitoring and inspection programs by Clinton management and DOCCS central office failed to detect any of the security deficiencies that contributed to the escape. Self-assessments by Clinton managers during 2011-2014 and site visits by a DOCCS assistant commissioner in 2014 and early 2015 inexplicably reported that security operations at Clinton were in full compliance with required standards. Central office audits also failed to examine key components of Clinton security. An April 7, 2015, memorandum from the DOCCS deputy commissioner for correctional facilities to all prison superintendents, which was prompted by an attempted escape of an inmate at another prison, emphasized the need for proper gate checks, inmate counts, and civilian shop and tunnel inspections. This alert, however, resulted in no action at Clinton. Ironically, Clinton received the memorandum at the very time Sweat was forging an escape route in the tunnels beneath the prison. Further, DOCCS failed to heed the lessons of a prior escape from a maximum-security prison. After two convicted murderers escaped from Elmira Correctional Facility in July 2003, a DOCCS investigation identified multiple security breakdowns as contributing causes. These lapses – deficiencies in night counts, cell searches, and contraband control, among others – are startlingly similar to the circumstances of the June 5, 2015 Clinton escape. Specifically, officers making rounds failed to notice the absence of the inmates, multiple cell searches overlooked a large hole the inmates had bored in the ceiling of their cell, and inadequate monitoring allowed the inmates to smuggle escape tools from a prison workshop. DOCCS took inadequate action to ensure that the deficiencies that enabled the escape at Elmira were not present or did not arise at other prisons. In February 2015, DOCCS’s Office of Special Investigations (OSI) conducted an investigation of alleged rumors of an improper relationship between Mitchell and Sweat. By OSI’s own admission, this investigation, which wrongly concluded the rumors were baseless, failed to interview a number of relevant witnesses and evaluate other evidence. A thorough investigation could have revealed Mitchell’s criminal acts and foiled the escape. 8 Summary of Recommendations of the Inspector General To address the failures and deficiencies identified by the Inspector General, Clinton management and DOCCS must implement substantial improvements in many areas. Of urgent importance, Clinton must take action to ensure that long-established requirements for front gate checks, night counts of inmates, cell searches, and tailor shop supervision are strictly followed. The pre-filling of night count slips must immediately cease. Tunnel and catwalk inspections, metal detector use, and tool control must also be strengthened. DOCCS and Clinton must examine the feasibility of installing cameras and other electronic systems to verify that required security checks are occurring. It is essential that Clinton management also implement a comprehensive program of regular and unannounced security audits to ensure compliance with all relevant policy. DOCCS’s oversight of security operations at Clinton and other prisons must be significantly improved. A comprehensive and substantive monitoring program, with effective follow-up, is necessary. The nature and extent of the systemic failures that contributed to the June 5 escape raise fundamental questions about the ability of DOCCS to oversee itself. The need for oversight is particularly apparent in view of subsequent allegations of abuse by DOCCS personnel at Clinton and other state prisons that have emerged in the wake of the escape. Additionally, in the course of this investigation and other investigations of DOCCS, the Inspector General found inherent flaws in OSI’s structure. The Inspector General recommends that OSI be restructured to ensure the quality and integrity of investigations, consisting of investigators who are not subject to return to facilities as correction officers. The Inspector General further recommends that DOCCS create a specialized unit with a staff possessed with the requisite expertise to conduct and oversee investigations, including those involving the use of excessive force against inmates by DOCCS personnel, reporting directly to the Commissioner of DOCCS. Finally, the Inspector General is creating a unit specifically designed and trained to audit and monitor DOCCS and ensure the integrity of its operations, policies, and practices. The Inspector General’s detailed recommendations are presented in the concluding section of this report. 9 Methodology of the Inspector General’s Investigation The Inspector General conducted a comprehensive investigation beginning on June 15, 2015. In the course of the investigation, the Inspector General conducted sworn interviews of more than 175 individuals, many of whom were questioned on more than one occasion. Current and former Clinton employees who were interviewed included all security staff assigned to the Honor Block, where Sweat and Matt were housed; other line and ranking officers assigned to duties relevant to the investigation; civilian supervisors and coworkers of Mitchell; Clinton management officials; and DOCCS executive management officials. Eleven inmates formerly housed on the Clinton Honor Block or employed in the Clinton tailor shops were also interviewed under oath. Mitchell was interviewed on two occasions pursuant to an agreement with Clinton County District Attorney Andrew Wylie requiring Mitchell’s cooperation with the Inspector General’s investigation prior to her sentencing. Palmer too provided testimony to the Inspector General pursuant to an agreement with District Attorney Wylie. In addition, the Inspector General reviewed approximately 40 hours of State Police and other law enforcement agency interviews of Mitchell, and approximately 15 hours of such interviews of Palmer. The Inspector General interviewed Sweat at Albany Medical Center and Five Points Correctional Facility on a total of four occasions totaling approximately 15 hours, and reviewed State Police and FBI interviews with him. The Inspector General conducted onsite examinations of the cells and escape route used by Sweat and Matt, as well as housing blocks, catwalks, tailor shops, and other relevant areas within Clinton. Among tens of thousands of pages of documents reviewed were DOCCS directives, Clinton procedures, staffing charts, inmate count slips, cell block and tailor shop logs, cell search records, unusual incident reports, inmate disciplinary files, DOCCS inspection and audit reports, and records of the DOCCS Office of Special Investigations. In accordance with Governor Cuomo’s directive regarding this investigation, the Inspector General consulted with corrections practitioners and experts unaffiliated with DOCCS, including Michael P. Jacobson, a widely recognized criminal justice scholar and former corrections executive. Jacobson served as Commissioner of the New York City Department of Probation from 1992 to 1996 and as Commissioner of the New York City Department of Correction from 1995 to 1998. From 2005 to 2013 he was president and director of the Vera 10 Institute of Justice and since 2013 has been professor of sociology at the Graduate Center of the City University of New York (CUNY) and executive director of the CUNY Institute for State and Local Governance. The Inspector General also consulted corrections officials from Minnesota, Pennsylvania, and Los Angeles County on security issues directly relevant to deficiencies identified at Clinton. The Inspector General is compelled to note that this investigation was made more difficult by a lack of full cooperation on the part of a number of Clinton staff, including executive management, civilian employees, and uniformed officers. Notwithstanding the unprecedented granting of immunity from criminal prosecution for most uniformed officers, employees provided testimony under oath that was incomplete and at times not credible. Among other claims, they testified they could not recall such information as the names of colleagues with whom they regularly worked, supervisors, or staff who had trained them. Several officers, testifying under oath within several weeks of the event, claimed not to remember their activities or observations on the night of the escape. Other employees claimed ignorance of security lapses that were longstanding and widely known. The Inspector General finds these misstatements and purported lapses of memory reprehensible. These actions may also violate state ethics laws and, in the case of uniformed officers, a sworn duty to uphold the law. 11 BACKGROUND Clinton Correctional Facility Clinton Correctional Facility, a maximum-security prison for men located in the Village of Dannemora in Clinton County, is the largest and third oldest of the prisons operated by the New York State Department of Corrections and Community Supervision (DOCCS). Clinton’s first buildings were constructed in 1844, when the prison housed inmates for work in nearby mines. The prison’s 30-foot-high main wall was erected in 1887 after the facility began housing general confinement inmates. Clinton is one of several prisons in the state to have maintained a death row, and between 1892 and 1913 Clinton’s electric chair was used to execute 26 inmates. A riot in 1929 resulted in the renovation or rebuilding of most of the prison’s structures. At the time of the escape, Clinton housed a total of 2,653 inmates: 1,917 in the main, wall-enclosed section and 736 in the adjacent annex. On that date, Clinton employed approximately 1,283 staff, of whom 990 of a potential fill rate of 999 were uniformed security personnel. Within the main section are eight multi-tiered housing blocks, a special housing unit, administrative buildings, a kitchen and mess halls, a hospital, chapel, recreation yards, and industrial shops. Housing units in the main section and annex include individual and double occupancy cells, single rooms, and dormitories. Clinton offers academic education, vocational and industrial training, as well as mental health and substance abuse treatment for its inmate population. The prison is located 20 miles northwest of the City of Plattsburgh and 70 miles south of Montreal. Its harsh winter climate and rugged and remote location in the northernmost part of the Adirondack Park have earned it the nickname “Little Siberia” and no doubt contributed to its history of very few escapes. Indeed, prior to the June 5 breakout, the last escape from within the main section of the prison occurred in 1912. The Department of Corrections and Community Supervision DOCCS was created in 2011 by the merger of the New York State Department of Correctional Services and the New York State Division of Parole. It currently operates 54 prisons housing approximately 53,000 inmates, and supervises approximately 36,000 parolees. With its headquarters in Albany, DOCCS employs approximately 29,000 staff with a 2015-16 fiscal year budget of more than $2.94 billion. 12 DOCCS has issued directives establishing standards and procedures that govern nearly all prison operations, ranging from food service to inmate frisks. The directives are supplemented and in some areas modified by operations manuals which are developed by each prison to address particular functions or needs. For example, while DOCCS’s directive on security requires that officers conduct a morning and evening count of inmates in their cells, the Clinton operations manual also requires night-time checks at 12 a.m., 2 a.m., and 4 a.m. DOCCS’s Division of Industries at Clinton DOCCS’s Division of Industries, or Corcraft, was established to reduce the cost of prison operations and teach inmates marketable skills. At present, Corcraft employs more than 275 civilians and approximately 2,100 inmates in 14 prisons. In addition to clothing, Corcraft produces highway signs, license plates and furniture, and offers printing, document conversion, and other services. Corcraft’s revenue in 2014 was approximately $48 million. Clinton serves as an apparel manufacturing site for Corcraft, producing uniforms, outerwear and underwear, and other clothing items for state and municipal customers. The approximately 350 inmates employed in Corcraft jobs at Clinton earn from $.26 to $.65 per hour, plus bonuses based on production. Eight active tailor shops are located in the multi-story Industry Building that overlooks the main wall on the south side of the prison. Clinton’s apparel shops received almost $10 million in orders in fiscal year 2013-2014. 13 THE PLANNING AND EXECUTION OF THE ESCAPE OF SWEAT AND MATT Preliminary Note The information presented in the following section of the report has been obtained from a number of sources, including sworn testimony, documents, photographic and physical evidence, and on-site observations. It is to be noted that a comprehensive account of the planning and execution of the escape must derive in part from the extensive testimony provided by Sweat, the only living witness to, and participant in, many of the relevant events. The Inspector General recognizes that questions will arise regarding Sweat’s motivation and credibility. Wherever possible, therefore, the information provided by Sweat under oath has been corroborated by other testimony and evidence. In instances where no independent corroboration exists, the Inspector General has found Sweat’s account credible and consistent with other known facts. David Sweat and Richard Matt David Sweat was 23 years old when he arrived at Clinton Correctional Facility in October 2003, sentenced to a term of life without parole for the July 2002 murder in Kirkwood of Broome County Sheriff’s Deputy Kevin Tarsia, who was shot multiple times by Sweat and an accomplice and run over by a vehicle driven by Sweat. DOCCS’s evaluation of Sweat upon his entry into the correctional system in September 2003 described him as “motivated by [a] lack of regard for life as well as for the criminal justice system compounded with the lack of emotional control.” Richard Matt’s incarceration at Clinton commenced in July 2008, when, at age 42, he began serving a sentence of 25 years to life for the kidnap, torture, and murder of businessman William Rickerson, Matt’s 76-year-old former employer, in Niagara County in December 1997. An assessment of Matt in June 2008 described him as motivated by monetary gain and exhibiting a callous indifference to life. Both Sweat and Matt had criminal histories and previously served time in state prison in New York. In 1997, when he was 17, Sweat pled guilty to a charge of attempted burglary and served approximately two years at DOCCS’s Washington Correctional Facility. He was released on parole in 1999 and completed parole supervision in 2001. Matt’s criminal history includes numerous arrests. In 1986 Matt was convicted of Assault in the Third Degree and sentenced to one year in the Erie County Correctional Facility. While awaiting sentencing in that case, Matt escaped by climbing the jail’s perimeter fence. He 14 was recaptured after five days. Later in 1986, Matt pled guilty to Possession of a Forged Instrument and was sentenced to an indeterminate sentence of 16 months to 4 years in state prison, a term he served at Coxsackie Correctional Facility. In January 1987, while incarcerated at Coxsackie, he was convicted of Escape in the First Degree for the Erie County jail escape. He was released on parole in 1988, but returned to prison in 1990 for violating parole. Three months later he was released again. In 1993, Matt was sentenced to 2-4 years for Attempted Burglary and incarcerated at Great Meadow Correctional Facility and Attica Correctional Facility until his release on parole in early 1997. While being sought for the December 1997 murder and kidnap of Rickerson, Matt fled to Mexico, where he was arrested and imprisoned for the knifing murder of an American working in the country. Shortly after his imprisonment in Mexico, according to a newspaper report, Matt was shot and wounded by guards during an escape attempt. After nine years of incarceration, Mexican authorities returned Matt to New York in 2008, and he went on trial in Niagara County in the Rickerson case. During his trial in early 2008, Niagara County Jail officials foiled an escape plan by Matt. When Sweat and Matt re-entered the DOCCS system at Clinton in 2003 and 2008, respectively, both were designated Central Monitoring Case (CMC) inmates. According to DOCCS policy, DOCCS’s Office of Special Investigations assigns CMC designation to inmates who “because of the nature of their crime, status, or behavior, require special evaluation and tracking of their movement through the correctional system.” DOCCS policy requires central office approval of the transport outside the prison of any CMC-designated inmate. Approximately 28 percent of inmates housed in the main section of Clinton inmates have CMC status. Matt’s designation as a CMC inmate resulted from his history of escape; Sweat’s was due to the heinousness of his crime. In an October 4, 2011, memorandum to front gate officers, Clinton’s then deputy superintendent for security identified Sweat too as an “escape risk” and advised that “all necessary precautions should be taken whenever it is required to move the inmate outside the facility, regardless of the reason.” Matt and Sweat also appeared on what Clinton officials colloquially refer to as the prison’s “Top 40” list. According to Clinton security officials, inmates are placed on the list, which in fact contains approximately 75 names, if they are deemed an escape, risk, committed a high-profile or sophisticated crime, or, while 15 incarcerated, received contraband from prison staff or manipulated staff. Notably, the Inspector General found that inmates assigned CMC status, identified as escape risks, or included on the Top 40 list are not subject to increased security during the time they are actually within Clinton. David Sweat, left, and Richard Matt during their incarceration at Clinton. (DOCCS photographs) Sweat and Matt Fired From and Regain Prison Tailor Shop Jobs Soon after their arrival at Clinton, Sweat and Matt began employment in Clinton’s Industry, or tailor shops, which are desired positions at Clinton because they can pay more than other prison work. To be eligible for Industry employment, inmates must have a General Educational Development degree or be enrolled in prison education courses with high grades in mathematics and reading. A program committee responsible for approving work assignments also considers an inmate’s criminal history and prison behavior record. At different times, both Sweat and Matt were removed from their tailor shop jobs for security reasons, but later were allowed to return. Sweat started Industry work in November 2003 and over the next nine years was assigned to various tailor shops. Civilian supervisors in the tailor shops uniformly described Sweat as a highly skilled worker. In Tailor Shop 1, where he was assigned beginning in February 2012, he assumed the additional duties of Instructor because of his abilities. As discussed in detail later in 16 this report, Sweat’s employment in Tailor Shop 1 was terminated in September 2014 due to concerns by security staff about his relationship with Joyce Mitchell, the shop’s civilian supervisor, and inappropriate comments he made to the Clinton industrial superintendent. Sweat was then assigned to the prison library as a clerk and typist. He resumed work in Industry in January 2015, assigned to Tailor Shop 8, where he remained until his escape. Matt began Industry work in August 2008, and in the ensuing years was assigned to four different shops. He was generally rated an average or above average worker. However, two incidents occurred between September 2011 and August 2012 that resulted in Matt’s removal from his tailor shop employment over security concerns. On September 14, 2011, while returning to his cell in the Honor Block after finishing work in Tailor Shop 2, Matt was subjected to a search at the metal detector station in the BBlock corridor. A correction officer discovered 12 sewing needles Matt had taken from the shop and hidden in the battery compartment of his hand-held radio. Officers then searched Matt’s cell and found a tattoo machine, a contraband item, taped under his bed. He was immediately removed from his tailor shop job, keeplocked in his cell, and, after being found guilty at a disciplinary hearing, confined in the Clinton Special Housing Unit until October 13, 2011. On October 25, 2011, only 12 days following his release from the Special Housing Unit, the program committee approved his return to employment in Tailor Shop 2. He was promoted two weeks later. Less than a year later, another incident resulted in Matt’s removal from tailor shop employment; this dismissal also proved temporary. On or about August 23, 2012, the civilian supervisor in Tailor Shop 2, where Matt then worked, discovered a note in the shop targeting her in an apparent extortion attempt. According to the supervisor, the unsigned, typewritten note demanded $500 in cash from her or threatened to reveal what the note claimed was her improper relationship with an inmate in the shop. The supervisor, who denied she had an inappropriate relationship with any inmate, took the note to the then industrial superintendent who brought it to the attention of then Deputy Superintendent for Security Stephen Brown and other security staff. Despite its extreme seriousness, Brown did not report the matter to DOCCS’s Office of Special Investigations (OSI). The internal Clinton investigation that followed included a two-day lockdown of Tailor Shop 2 and an examination of prison typewriters accessible to inmates in an effort to discover the 17 source of the note. While the investigation was ongoing, the then Clinton security lieutenant, ordered that Matt and six other inmates in Tailor Shop 2 “be removed from all tailor shops for security reasons.” The specific reason for this action, according to August 23, 2012 memoranda that the lieutenant sent to the program committee regarding each inmate, was that Matt and the other inmates were “implicated in an extortion attempt on [a]civilian staff member.” Despite a request to Clinton management and a search by the Inspector General, no records relating to the internal investigation, including the extortion note itself, were located. In addition, the Inspector General’s interviews of security and civilian staff, and an inmate assigned to Tailor Shop 2 at the time did not reveal the involvement of Matt or any other inmate in the extortion attempt. In fact, neither Matt nor any other inmate was issued a misbehavior report regarding this matter. For six months following his ouster from Tailor Shop 2, Matt was unemployed for a period and then assigned as a “porter,” or cleaner, in Upper F-Block. On February 19, 2013, the program committee granted Matt’s request to return to tailor shop employment, assigning him to Tailor Shop 1. Correction Officer Eugene Palmer testified that he advocated for Matt’s return, the first of a number of favors by Palmer on behalf of Matt. The Inspector General’s investigation revealed that the program committee approved Matt’s return to a shop job without inquiring into the circumstances of his removal. Housing in Honor Block At the time of the June 5, 2015 escape, Sweat and Matt occupied adjacent cells on the third, or top, tier of A-Block, the housing unit that served as the Honor Block at Clinton. Honor housing is utilized widely in corrections in New York and elsewhere as an incentive and reward to inmates for good behavior. DOCCS delegates to prison superintendents the authority to decide whether to implement honor housing programs in their facilities. Under Clinton policy at the time, inmates were eligible for housing in the Honor Block without consideration of the length of their sentences, the crimes for which they were incarcerated, or previous criminal records, including histories of escape, so long as they had not committed a serious disciplinary infraction and had satisfactorily participated in prison programs during the preceding nine months. Inmates were subject to removal from the Honor Block if they received a misbehavior report resulting in seven or more days of keeplock, or confinement in their cells, or the loss of one or more privileges for 21 or more days. 18 One side of a typical three-tier housing block at Clinton. (Inspector General photograph) As a physical structure, the Honor Block at Clinton is similar to other housing units in the maximum-security, or main, section of the prison: three tiers of cells, each approximately eightfeet by six-feet, arranged in two back-to-back rows separated by a narrow passage, or catwalk, that provides access to electrical, plumbing, and ventilation systems. Honor Block inmates, grouped into six “companies,” were subject to the same security measures as other prisoners. Rules for permissible attire were also the same: in general, inmates were required to wear green, prison-issued pants, but civilian shirts, sweaters, sweatshirts, and footwear were allowed. Honor Block inmates were entitled, however, to a number of privileges not allowed elsewhere in the prison, including longer recreation periods on weekdays and weekends when they were allowed to remain in their cells or congregate on the “flats”, or open areas, of the first tier, where they could cook and engage in recreational and social activities. Honor Block inmates were also permitted more locker and shelf space in their cells and more frequent, and more private, showers. As a result of these benefits, according to Palmer, a tailor shop escort officer with parttime duty in the Honor Block, “none of the inmates really ran their mouths” and were less likely to misbehave. At the time of the escape, the Honor Block housed up to 180 inmates in 174 cells, including six cells that at times held two inmates. Matt was accepted in the Honor Block in June 2009, having been incarcerated at Clinton for 11 months without any rule infractions. Consistent with Clinton policy, his history of escape and attempted escape had no bearing on his eligibility for honor housing. His tenure in the 19 Honor Block, however, was not without incident. As a result of the September 2011 disciplinary matter described above, Matt was removed from the Honor Block and confined in Clinton’s Special Housing Unit for 30 days. Thereafter, he was housed in various blocks before returning to the Honor Block in June 2013. Sweat was accepted in Honor Block housing in November 2010, having served more than seven years at Clinton without a disciplinary charge. In September 2014 Sweat was found guilty in a disciplinary hearing for making inappropriate comments to a civilian supervisor. However, his punishment of 30 days of keeplock was suspended, and he remained in the Honor Block until his and Matt’s escape. A friendship developed between Matt and Sweat in November 2010 when their housing in the Honor Block first overlapped. They occupied adjacent cells from August 2013 to September 2014 and again from late January 2015 until their escape. One inmate who was housed and worked with Matt and Sweat described Sweat as “very, very self-sufficient in all ways”; whereas Matt was “sociable” and “gregarious.” Despite their differences in age and personality, Sweat and Matt became friends, based in part on a shared interest in art. Sweat recalled admiring Matt’s paintings, including one depicting a dog in which “you could see every hair . . . [it] was absolutely beautiful.” Inspired by Matt, Sweat took up painting and drawing, and quickly developed his talents. When Matt was expelled from the Honor Block in 2011, Sweat sent him gifts of tobacco, rolling papers, and food. “That really strengthened our friendship,” Sweat recalled. Staff and inmates described Matt and Sweat as “buddies,” and they sat at work stations near each other during the time they were both assigned to Tailor Shop 1. Sweat and other inmates called Matt by a prison nickname, “Hacksaw,” a reference to the dismemberment of his murder victim. Joyce Mitchell’s Improper Conduct in Tailor Shop 1 Mitchell began employment at Clinton in 2008 as an Industrial Training Supervisor, a civilian position in Corcraft’s apparel manufacturing operation at the prison. Between 2008 and 2013, she worked as a “relief” employee covering staff absences in various shops and briefly as the supervisor in the tailor shop in the prison’s Assessment Preparation Program Unit. In November 2013, she was assigned to Tailor Shop 1, where she remained until the day of the escape. Mitchell’s husband, Lyle Mitchell, has been employed at Clinton since 2005 as an industrial training supervisor. 20 As early as 2012, Mitchell’s inappropriate interactions with inmates were noticed by coworkers and supervisors. Mitchell “treated them more as an employee or a friend . . . she didn’t keep the distance,” Vicki-Lynn Safford, the Industry quality control supervisor, testified. Bradley Streeter, a general industrial training supervisor and Mitchell’s direct supervisor beginning in 2013, described her as an “inmate lover” who “tried to sweet talk them into getting things done her way.” Mitchell herself said she found it difficult to maintain a proper separation from inmates. “I will visit with the guys,” she told investigators. “It’s like you get a rapport with them because you are in that same room with them every day of the week,” she added. The then senior industrial superintendent attempted to address Mitchell’s conduct, but with no success. At the senior industrial superintendent’s request, managers daily monitored Mitchell’s behavior and reported problems to her. However, when the senior industrial superintendent took action, Mitchell resisted. In response to a 2012 counseling memorandum from senior industrial superintendent, Mitchell complained of harassment to then Clinton Superintendent Thomas LaValley. In 2013, after receiving a performance evaluation that included criticism of her, Mitchell filed a grievance. Moreover, when she sought LaValley’s support in dealing with Mitchell, she felt stymied. Mitchell, on the other hand, was emboldened. The senior industrial superintendent recalled Mitchell and her husband returning from a meeting with LaValley, “walking by my office whistling and smiling because they had been to the superintendent and the superintendent was telling us to back off.” In November 2013, the senior industrial superintendent reluctantly assigned Mitchell to supervise Tailor Shop 1, stating that staff shortages and production pressures left her no option. Soon after Mitchell’s appointment to the shop, the senior industrial superintendent retired and was replaced by Scott Scholl, the assistant industrial superintendent since 2008, a much less effective manager. Although Mitchell’s behavior did not improve, it never became a matter of serious concern for Scholl, who testified, “I don’t know that it ever came to me to the point where, in my opinion, I thought it needed to be put on paper or to pull her out.” The Inspector General found that during the time of Mitchell’s assignment to Tailor Shop 1, an environment of permissiveness prevailed in the shop in which rules governing the interaction of staff and inmates were not adequately enforced. For example, civilian supervisors and security staff were aware that both Mitchell and her husband frequently provided food to Sweat, Matt, and other inmates, but did not intervene. An inmate who worked in Tailor Shop 1 21 at the time testified that Allan Trombley, the correction officer assigned to the shop, distributed the Mitchells’ baked goods to inmates. Another inmate testified he observed Mitchell giving Matt “cookies, cakes . . . meals that were prepared, like venison, sauce, biscuits.” Yet another inmate testified that Mitchell once brought Sweat a Big Mac from McDonald’s. Sweat said he was always happy to receive gifts of food from Mitchell, as this saved him money. Sweat stated: “You know, fucking only reason I’m working for the most part is to buy food anyway so I don’t have to go to mess hall. So when a civilian offers you food . . . I’ll take that, no problem. It was, ‘Oh, I got a new recipe, you want to try it.’ I’m making this or I’m making that, or whatever. Okay sure, why not. I didn’t turn food down.” Civilian and security staff also requested personal sewing favors of Sweat, a skilled sewer, which he gladly performed without payment but with a calculated purpose. “I would just do it to do it, because then people would leave me alone,” he stated. Mitchell also openly ignored supervision. As described by Trombley, “Her outlook was, ‘I’m going to do what I want to do, whether they like it or not.’” With regard to security staff, Mitchell was similarly defiant. “I need to be able to run the shop. [The officer is] here to help me . . . I’m the one to tell the [inmates] where to go,” she said. Although Mitchell had previously met both Sweat and Matt when temporarily assigned to other shops where they worked, it was in Tailor Shop 1 that she first interacted with both inmates on a regular basis and developed personal relationships with them. Recalling Mitchell’s behavior in Tailor Shop 1, Safford testified, “She always flirted around the shop and laughed and stood close to all inmates, but it was more so with Sweat and Matt.” In their different ways, Sweat and Matt made strong impressions on Mitchell. Sweat “usually was pretty quiet,” Mitchell stated, and “very intelligent.” She described Matt as the “top dog” to whom other inmates gravitated. Matt, she said, was “confident,” a “dominant personality” and a “bull-shitter.” Both inmates, she recalled, were “always nice” to her, which “made me feel good.” An inmate who observed these interactions had perhaps a clearer perspective, calling Sweat and Matt “master manipulators.” 22 Matt and Sweat Manipulate Correction Officer Eugene Palmer and Others While housed in the Honor Block, Matt and Sweat developed a mutually beneficial relationship with Correction Officer Eugene Palmer, a 27-year veteran of Clinton who for the previous eight years was assigned to escort inmates to and from the Industry Building and also regularly worked weekend overtime shifts in the Honor Block. The Inspector General found that Palmer’s interactions with Matt and Sweat, as well as with other inmates, were at times unauthorized and improper. Palmer described himself as the “go-to guy” whom “everybody looked up to . . . in the jail.” Palmer testified: “I was one of the people that they could come to, officers, and say ‘Hey, this guy’s giving me a problem, or in my packages, or I can’t get a hold of my wife, or, however, I need to speak to my counselor.’ So, when my job as an escort officer, I can go pretty much anywhere I wanted to . . . I’m mobile, so I can go see their counselor and say, ‘Hey, this is --, what can we do about this.’” According to Mitchell, Matt and Sweat were “Palmer’s boys,” and Palmer was their “boy,” each looking out for the other. An inmate testified that Palmer and Matt “were tighter than two peas in a pod.” Indeed, Palmer testified that he and Matt had developed such a trusting relationship that Matt had vowed to kill any inmate who assaulted Palmer. Palmer described Matt, with whom he conversed “pretty much every day,” as a “smooth talker [who] always had something to say.” In contrast, Sweat, according to Palmer, “never said nothing . . . never caused no problems.” Both prolific artists, Matt and Sweat produced in their cells many paintings and drawings which they provided to a number of prison staff. These items became a kind of prison currency intended by Matt and Sweat to curry favor. According to Sweat, “When we do . . . paintings, we give it to you exceptionally cheap because we know that at some point we’re going to be in a bind, or we might need help with something.” While no employee testified to having paid for any of these works, staff members’ actions violated DOCCS policy prohibiting acceptance of gifts or purchase of items from inmates. The primary recipient of artwork from Matt and Sweat was Palmer. Indeed, over several years Matt gave Palmer at least 10 paintings and three drawings, most depicting members of Palmer’s family. Palmer described how this exchange of favors developed: “[A]fter I accepted the first one, then he kept coming back, ‘Well … do you want somebody in your family drawn, 23 or … friends or whatever relative.” When Matt had finished a painting, Palmer retrieved it from Matt’s cell and carried it, wrapped in paper, out the front gate of the prison unchecked. In addition, Palmer testified that he received from Matt information about potential trouble in the prison which he reported to Clinton management. However, Palmer was not assigned to the Crisis Intervention Unit, the entity responsible for gathering intelligence within the prison. Further, the information Palmer reported appears to have had little value. Former Clinton First Deputy Superintendent Donald Quinn testified that Palmer was “real dramatic” and his information “usually . . . didn’t pan out.” In one instance, according to Quinn, Palmer warned, “You’re going to lose your prison . . . It’s a powder keg and it’s about to explode. My informant tells me that when it goes, they’re going to show no mercy.” However, when pressed for details, Quinn testified, Palmer was unable to provide evidence to support his claim. Quinn also termed Palmer’s unsolicited tips the “disinformation highway.” Former Superintendent Steven Racette testified that Clinton executive management “referred to [Palmer] as Chicken Little, the sky was falling . . . [we] quickly figured out that his information wasn’t reliable.” During the same period, Sweat provided Palmer with approximately half a dozen paintings. Several days after the escape, Palmer burned a number of Matt’s paintings that were in his possession and hid several of the paintings Sweat had given him in the woods near his residence. A Sweat painting obtained by Palmer shown in woods near Palmer’s home. (State Police photograph) 24 In exchange, Palmer provided Matt and Sweat with a number of benefits. These included supplying both inmates with paints and other art materials, which, although seemingly innocuous, nonetheless were contrary to prison contraband policy. Palmer admitted he violated policy by purchasing and giving to Matt tubes of oil-based paints and paint brushes. He also provided Matt photographs that were the source of images he painted. Palmer also testified that he provided inmates with televisions and permits for their use in exchange for information. DOCCS policy allows inmates to purchase televisions in the commissary or bring sets with them if transferred from other prisons. Outside this prescribed procedure, Palmer gave favored inmates televisions that had been confiscated and to which he had access. Palmer testified that he provided televisions to both Matt and Sweat, and to other inmates at Matt’s request. According to Palmer, Clinton management knew of his actions and allowed them to continue. Palmer’s largesse earned him the respect of many inmates. According to one inmate, “These fucking guys used to treat Palmer like he’s a fucking rock star around here . . . whatever door he came in, they flocked to him.” More significantly, Palmer took a number of actions, some of which assisted Matt’s and Sweat’s escape. As described in detail below, these included frequent escorts of Matt from the tailor shop to his cell, bypassing metal detector checks; access for Matt and Sweat to the catwalks behind their cells; giving Matt warning of a possible cell search and concealing contraband that might be found in the search; assisting Sweat in his reassignment to the tailor shop and relocation to a cell next to Matt; and transporting contraband meat to Matt and Sweat in which escape tools were concealed. As a result of his relationship with Palmer, Matt’s status in the Honor Block was enhanced as he was in a position to requests favors from Palmer for other inmates. For example, inmates wishing to have their cells’ electrical system upgraded to operate hot plates, appealed to Matt for assistance. Palmer said he would allow Sweat access to the catwalks to perform the upgrades on the cells designated by Matt. According to Palmer, Matt also produced artwork for other Clinton security staff, including Allan Trombley, the officer assigned to Tailor Shop 1. Palmer testified that Trombley requested and received from Matt in 2013 or 2014 a painting depicting Trombley and his brother. Palmer stated that he saw the completed painting, and that he and Trombley discussed it. Trombley, however, testified that although he requested a price quote from Matt for this 25 painting, it was never produced. Regardless of which testimony to credit, Trombley’s interaction with Matt was improper and indicative of the failure to enforce a necessary separation between inmates and staff, particularly in Tailor Shop 1. Moreover, Palmer commissioned at least six works of art from Matt during the period 2008 to 2014 to give to his girlfriend, Clinton Correction Officer Mary Lamar. Palmer said that Matt did paintings and pencil sketches of Lamar’s relatives. When questioned by the Inspector General, Lamar acknowledged receiving artworks as gifts from Palmer, but claimed not to know their source. “I assumed that it came from an inmate,” Lamar testified, but never asked Palmer because “I didn’t want to know.” However, other testimony contradicts this claim of ignorance by Lamar. Palmer testified that Lamar was aware of the source of the artwork and “wasn’t always comfortable with that.” In addition, Palmer and two Honor Block inmates testified that on one occasion Lamar viewed one of the works from outside of Matt’s cell and was pleased with the likeness. According to one inmate, Lamar was “in tears in front of [Matt’s] cell looking at it . . . she was just so happy with the way it came out.” The other inmate, who was housed six cells from Matt on the Honor Block, recalling this encounter in August or September 2014 encounter, testified that Lamar “thanked [Matt]” and “shed a few tears.” Palmer stated that a sergeant also received a painting from Matt, in 2103, while she was still a correction officer at the facility. According to Palmer, this sergeant gave him a photograph as a basis for a panting, as well as several tubes of paint and brushes, all of which he delivered to Matt at her request. The sergeant denied in testimony that she requested or received a painting from Matt. In late 2014, according to Palmer, another officer also requested and received a painting from Matt. The officer is assigned to the prison’s package room, where inmates’ incoming and outgoing bulk items are handled. Palmer said that he and the officer discussed Matt’s artwork one weekend when Palmer brought Matt’s artwork to the package room for shipping. According to Palmer, the officer provided a photograph of himself and his wife, which Palmer delivered to Matt. Sweat Removed from Tailor Shop 1 Mitchell told investigators that she was unhappy in her marriage and lonely, and found comfort in her relationship with Sweat and Matt. Mitchell said they discussed their personal 26 lives with one another. Sweat recalled that Mitchell “kind of showed an interest in me, kind of right off,” and that over time her attention became “a little too personal . . . every time you try to walk past her desk or something, she’d call me up and start a conversation with you about really nothing, so I’d be trying to get away from the desk, she just wouldn’t let me leave.” Other staff and inmates also noticed that a personal relationship had developed between Mitchell and Sweat. A civilian coworker of Mitchell testified that she observed Mitchell with her arm around Sweat’s shoulder on multiple occasions. An inmate who worked in Tailor Shop 1 at the time said it was obvious that Mitchell and Sweat had some sort of a relationship, having seen “lots of laughing, giggling” between them, and that other inmates were talking about it. Another inmate stated that Mitchell’s “body language was different when she was with [Sweat] . . . I could tell that Joyce was interested in David.” By the summer of 2014, this relationship had become the cause of significant trouble in the shop. On July 12, 2014, the Clinton administration received an anonymous, handwritten letter, believed to be from an inmate, containing several allegations of improper conduct in Tailor Shop 1. The letter claimed Mitchell and Trombley engaged in racial bias by purportedly filing misbehavior reports only against “Latinos,” never against “white guys and many of the black guy.” [sic] The letter further alleged, “It’s funny that she goes to [Tailor Shop 9, the unstaffed spare parts room], next door with the same guy once or twice a week for 3 to 5 minute[s] and come out with nothing. I have notice that since I start it working here 4 the past 5 months.” [sic] Although unnamed in the letter, it was clear to staff and inmates in the shop that Sweat was the referenced “guy.” An inmate provided partial corroboration of the allegations, testifying that Mitchell and Sweat left the shop together “a few times [for] five to 10 minutes.” Palmer testified that while he doubted it, some staff believed, based on the note, that Mitchell and Sweat were having a sexual relationship. According to the inmate, Mitchell was enraged when she read the note, exclaiming loudly in the shop, “I want to know who the fuck is this anonymous guy who wrote me up.” Indicative of her inappropriate interactions with Sweat and Matt, Mitchell allowed both inmates to read the letter, hoping, she testified, they could help her identify the author. As with the August 2012 extortion note, Clinton’s executive management failed to refer the July 2014 allegations to the DOCCS Office of Special Investigations, deciding again to handle a serious matter internally. Executive management forwarded the letter to Captain David 27 Lucia, who testified that he referred it to Lieutenant Stephen Dubrey for investigation. Scott Scholl, the industrial superintendent, testified that he recalled the letter having been investigated by Sergeant Kris Mullady, the Industry security supervisor. Mitchell testified that she prepared a memorandum to the administration denying the allegations. Both Dubrey and Mullady testified under oath to the Inspector General they had no recollection of investigating the matter. Nevertheless, the incident was evidence that a personal relationship had developed between Mitchell and Sweat, and that it was causing problems in the shop. Several weeks later, a second incident occurred in Tailor Shop 1. On September 15, 2014, Sweat, while discussing shop matters with Scholl, spoke rudely about another civilian employee. Scholl testified that Sweat, referring to an employee he believed had mishandled a supply order, asked, “So, did you take care of that dumb bitch that fucked up . . . the order for the zippers?” The next day, September 16, 2014, Scholl reported Sweat’s comment to Lucia. In addition to receiving the report of Sweat’s profanity, Lucia, in a sworn statement to the State Police, advised that he then learned that Sweat “was being too close to a civilian staff worker, Joyce Mitchell.” At Lucia’s direction, Sweat was immediately removed from shop employment “for security concerns” and escorted back to the Honor Block where he was keeplocked in his cell. Lucia also instructed Scholl to prepare a misbehavior report against Sweat for his inappropriate comments. This would be Sweat’s first disciplinary infraction in 11 years of incarceration at Clinton and the only misbehavior report written by Scholl in 10 years. No formal disciplinary action was taken regarding Sweat’s relationship with Mitchell. Although he considered the infraction “bogus,” Sweat pled guilty at his disciplinary hearing on September 18, 2014. Lieutenant Charles Durkin, the hearing officer, imposed a punishment of 30 days of keeplock and loss of commissary, telephone, and package room privileges. Durkin suspended the punishment due to a number of factors: it was Sweat’s first infraction; the misconduct was not related to security and did not involve violence; and he deemed Sweat’s comment to Scholl merely “off the cuff.” Suspension of the punishment allowed Sweat to remain in the Honor Block. Notwithstanding the misbehavior report, Durkin said he believed that the actual reason for Lucia’s order was concern that Sweat “was becoming a little too familiar” in the shop, and that the misbehavior report was “the avenue they took” to remove him. An inmate was more direct, testifying that Sweat was removed because “it was said he was having sexual relations 28 with Miss Mitchell.” Based on Lucia’s concerns about Sweat and Mitchell and the misbehavior report, the program committee formally terminated Sweat’s employment in Tailor Shop 1. Dismissal from the tailor shop was deeply distressing to Sweat for two reasons. Not only had he been accused, wrongly he insisted, of an improper relationship with Mitchell, he was also deprived of the earnings he relied on to purchase much-desired food items from the prison commissary. “I was devastated . . . I lost my money . . . the money was a big thing, because that was my food,” he said. “They took everything I had . . . and . . . locked me up . . . for something I didn’t do.” Adding to his sense of injustice, he was relocated from his cell next to Matt to the first floor of the Honor Block for two weeks after the disciplinary action. That first-floor cell, Sweat stated, was “in front of the damn sports TV . . . I don’t watch sports . . . everybody sitting there . . . it’s horrible.” It is not surprising that Sweat’s removal from Tailor Shop 1 also upset Mitchell, who, by this time, had developed what she described as “kind of” romantic feelings for Sweat. Mitchell’s feelings for Sweat were apparent to inmates in the shop, including one who had worked there with Sweat for approximately two years. This inmate stated, “She really had a crush on Sweat. There’s no question about that. A serious crush.” According to another inmate assigned to the shop at the time, “When Sweat got fired, Mitchell cried [and] wanted to have a drink when she got home [and] was mad [and] hard on everybody for a week.” Yet another inmate stated he overheard Mitchell tell Matt, “Hurry up and get Dave back here, I’m horny as fuck.” Safford testified that Mitchell “every week would ask for Sweat to be reassigned back to her shop.” Mitchell herself admitted, “I did cry,” when Sweat was removed from the shop, but claimed it was “because you want to succeed at what you’re doing, and . . . with him being gone it was going to hit the shop.” Significantly, however, management took no action against Mitchell, despite clear signs of inappropriate behavior and her own later acknowledgement to investigators that she had been a “screw-up” for “always talking” with Sweat. As noted, based on past experience, supervisors were reluctant to bring charges against, or even reprimand, Mitchell for such behavior. To do so, they feared, would likely provoke claims of harassment from Mitchell and possibly from her husband, Lyle Mitchell, as well. Moreover, as Sweat observed, he alone was targeted because “[management] didn’t want to make a fuss . . . didn’t want to make it look bad on Mrs. Mitchell and have an issue between [Mitchell and her husband].” Although Scholl said he told Mitchell 29 that “maybe she’s a little too comfortable with her inmates, she needs to step back and not rely on them so much,” when Mitchell asked if he had documented her conduct, which could be a basis for discipline, he assured her “No.” Trombley said he too spoke to Mitchell about her behavior in the aftermath of Sweat’s removal, telling her, “Don't be any more sociable than you have to,” but with little effect. According to Trombley, “[S]he basically agreed with me, for, I don't know how long, it was a while before she actually got back into being out there on the floor a little bit more than normal.” Matt Cultivates a Relationship with Joyce Mitchell In the summer and fall of 2014, Matt’s influence in Tailor Shop 1 took firmer root. After Sweat’s removal, and with Mitchell’s support, Matt assumed the role of Instructor, although not formally designated as such. Like Sweat prior to his removal, Matt also was now the inmate Trombley permitted to enter Tailor Shop 9 with Mitchell, ostensibly to retrieve sewing machine parts. Further, Matt exploited his relationship with Palmer to increase his power and status in the shop, even to the extent that he, in fact, influenced decisions to remove particular inmates from the shop. As Palmer himself acknowledged, he would act to expel from the shop inmates Matt had identified as troublesome to Mitchell: “[Matt] would tell me stuff that was going on [in] his shop . . . He would say, ‘Hey, this guy here is being an asshole in the shop. . . . ’ So, when he would tell me things, I would go and see Tillie [Joyce Mitchell], and I’d say ‘Tillie . . . you got a problem with this guy?’ ‘Well, yes we do,’ or however she would come about it. So then . . . I’d talk to the officer, said, ‘OK, here’s . . . if you see any [misbehavior] . . . write him [up] and we’ll get him out of the shop.’” As one inmate described Matt’s influence in the tailor shop, “If you didn’t kiss Matt’s ass, then your days were numbered.” In the words of another inmate, after Sweat’s removal the shop became the “kingdom of Matt.” In Sweat’s absence, Matt also began to focus greater personal attention on Mitchell. Mitchell recalled that Matt became “flirtatious;” he “made me feel special.” More significantly, Matt began asking more favors of Mitchell, revealing her willingness to break prison rules for his benefit and laying the foundation for the escape nine months later. Even before Sweat’s removal, Matt and Mitchell had traded favors. At Matt’s request, on August 22, 2014, Mitchell purchased two pairs of lighted reading glasses on eBay for $9. Matt told her that he and Sweat wanted the eyeglasses so they could paint in their cells at night. The eyeglasses apparently were 30 also used in the escape, as a piece of one pair, with a functioning light, was found in a prison tunnel. Sweat said he and Matt also had “taken other lights off of machinery [in the shop] . . . for our easels while we were painting.” Light from tailor shop sewing machine found in Sweat’s cell, top, and part of lighted eyeglasses, smuggled by Mitchell to Matt and Sweat, found in a tunnel after escape. (State Police photographs) According to Mitchell, she carried the two pairs of eyeglasses into the prison and gave them to Matt in the shop. In exchange, Matt produced a painting of Mitchell’s son based on a photograph she had carried into the prison and handed to Matt in the shop. When the 11-inchby16-inch painting was finished, Matt notified Mitchell and Palmer. Palmer then retrieved the 31 painting, wrapped in brown paper, from Matt’s cell, carried it out the front gate of the prison, and left it for Mitchell in her car. As before, front gate officers did not examine Palmer’s package or ask him about it. In the following weeks, Mitchell, at Matt’s request, purchased a pair of exercise gloves. After bringing them into the shop, Mitchell handed the gloves to Palmer, who carried them to Matt’s cell. In return, Matt produced another painting for Mitchell, this one depicting her two pet dogs. Palmer later transported this second painting out of the prison and placed it in Mitchell’s vehicle. Mitchell asked Matt for a third painting, a family portrait she planned to give to her husband as a wedding anniversary gift the following April, but he never produced this work. Matt’s painting of Mitchell’s pet dogs received in exchange for workout gloves. (State Police photograph) At about this time, Matt asked Mitchell to place a telephone call to his daughter to confirm she received a painting he had mailed her, and, as Mitchell recounted, to “make sure she was OK.” According to Mitchell, she knew that calling Matt’s daughter on her cell phone from home “was wrong” and could result in her termination. She said she even told Matt’s daughter, “I [am] not supposed to be doing this.” Significantly, Mitchell’s improper actions regarding the paintings were known to her husband, Lyle Mitchell, also a civilian employee at Clinton. Lyle Mitchell testified that in late 32 2014 he was aware that the glasses and gloves his wife had smuggled into the facility were given to Matt in exchange for paintings, and that if she were caught she might be fired. After Joyce Mitchell brought home the second painting, Lyle Mitchell said, he warned her about her actions: “I told her . . . ‘Never, ever again. It ain’t worth losing your job over.’ She said, ‘Never,’ and she never – until I found out she was getting the [family portrait for him as a gift], but she never got it.” Lyle Mitchell did not report his wife’s actions to any Clinton official, but acknowledged in his testimony that “I guess I should have.” Notwithstanding this, Lyle Mitchell testified he would “probably not” alert Clinton management to his wife’s wrongdoing if he had another chance to do so. He placed the burden of preventing her smuggling contraband into the prison squarely on the shoulders of Clinton’s front gate security personnel: “If they were checking our bag to come in, I’ll guarantee you she’d never brought that in.” In addition, Lyle Mitchell never reported that Palmer was assisting correction officers and civilian staff in obtaining paintings from Matt. “[T]here’s nothing worse than being a snitch in jail,” Lyle Mitchell offered as an excuse for his inaction. During this period Mitchell purchased and provided additional contraband items to Sweat and Matt. Sweat said that after smuggling the items into the shop, Mitchell placed them in the storage box by Matt’s sewing station in the morning before the correction officer and inmates arrived or at noon when the officer and inmates were at lunch in the mess hall. An inmate who worked in Tailor Shop 1, said he observed Mitchell putting pepper containers in a box beneath Matt’s sewing desk while other inmates were at lunch. Indeed, starting as early as October 2014 and continuing to within days of the escape, Mitchell smuggled in more than 70 containers of black and cayenne pepper, items not sold in the prison commissary. After delivering the pepper containers to Matt, Mitchell said, she watched him open them and remove the aluminum foil seals, presumably to evade discovery by the metal detector. Mitchell said she intended the pepper for Sweat to use as barter for food from other inmates because, after his removal from his tailor shop job, he lacked sufficient funds for commissary purchases. Sweat said he believed Mitchell felt responsible for his removal from the shop, and brought him the pepper and other food items, to ease her guilt. On at least 17 occasions beginning at this time, Mitchell also purchased and smuggled in 10-ounce packages of Café Bustelo coffee. In some instances, Mitchell said, she emptied the 33 coffee into a plastic bag before carrying it into the prison, making it easier for Matt to hide the coffee in his clothing and carry it to his cell. Mitchell said she also smuggled in several decks of pinochle cards and packages of candy for Matt and Sweat. Over time Mitchell had further contact with Matt’s daughter, exchanging text messages with her on a number of occasions. In one exchange, according to Mitchell, she informed the daughter that Matt’s sore back was feeling better, and the daughter expressed her appreciation that someone was looking out for her father in prison. At Matt’s request, Mitchell also telephoned the wife of another Clinton inmate to convey anniversary wishes from the inmate. By the end of the year, Matt understood that in Mitchell he had a willing smuggler of contraband. By this time, too, Mitchell was confident she could carry prohibited items into the prison without discovery as front gate officers rarely inspected bags. Mitchell’s willingness to provide Matt and Sweat with prohibited items would soon be put to a greater test. The Decision to Escape and the First Tools Smuggled by Mitchell In January 2015, Sweat said, he and Matt first discussed the idea of escaping from Clinton together. Granting that the “whole time we were in prison, the whole point was getting out, getting free and getting away,” it was early in the new year that Sweat and Matt began contemplating an actual escape. Sweat said he was motivated in large part by his belief he had been treated wrongly in his removal from Tailor Shop 1 the previous September. As a result of that incident, according to Sweat, “I said, ‘You know what, fuck it, man. I just want to get out of this place. I just want to be free. I want to go live somewhere away from everybody.” Mindful of Matt’s interactions with Mitchell, which led him to believe she could be a source of escape tools, Sweat began to think that an escape might be possible. Sweat recalled Matt telling him of Mitchell, “She’s fucking nuts, she’ll bring us whatever we want, just tell me what you need and I’ll get her to bring it in.” At the same time, Sweat was aware that Mitchell harbored “some kind of star lust thing in her mind where she was like in love with me,” and he thought he could exploit Mitchell’s feelings for him to assist in the escape. Sweat told investigators he initially contemplated an escape possibly more audacious than the one that actually occurred. Sweat said he had detected a potential vulnerability in the locking mechanism of his cell door, and he thought he might be able to open the door, make his way out of the cell block, and then cross the Industry yard to the prison’s 30-foot-high main wall. 34 There, he would use a makeshift rope and hook to scale the wall, unseen by correction officers “sitting in their tower and watching the damn TV or something,” and descend to the street below. “I could have probably just made it over the wall in just a couple seconds, took the rope and everything, the hook and everything, down and gone.” Before attempting such a plan, Sweat needed Mitchell to provide one or more star-headed security bits to remove screws in his cell door. To make clear the type and size of bit, Sweat made an impression of the screw head in a small lump of putty, then painted the dried putty and pressed it on a piece of notepaper to create an image. Sweat gave the note to Matt to deliver to Mitchell in the tailor shop. Mitchell purchased a boxed set of the bits at a store in Malone and, as Sweat had instructed in his note, smuggled in three bits ˗ the one closest in size to the image, plus the next smaller and larger bits. Mitchell handed the bits to Matt at his sewing station in the shop. According to Sweat, Matt smuggled the bits to his cell by concealing them in another inmate’s headphones, which are not routinely scanned when inmates pass through metal detector in the BBlock corridor at the end of the day. Matt then handed the bits to Sweat during recreation on the first-level “flats” of the Honor Block. Once Sweat had the bits and tried using them, however, he found they were too short to grasp firmly enough to turn with his fingers. Therefore, he requested from Mitchell, through Matt, a second delivery consisting of Allen-type wrenches with star-heads. Mitchell said she bought the wrenches, carried them into the prison, and, after handing them to Matt in the shop, saw him hide them in a set of headphones for smuggling back to his cell. These tools, too, Matt passed to Sweat during recreation on the “flats” in the Honor Block. Despite now having a more useful tool, Sweat said he abandoned the plan because Matt “can’t climb walls . . . he was out of shape.” According to Sweat, Matt then proposed an alternative, suggesting, “We’ll get in the sewer, something like that” The idea struck Sweat as feasible. “[L]et me give it some thought,” he told Matt, “Maybe we can do [it] . . . There’s got to be a way to get to the sewer system, something with all the pipes downstairs . . . they can’t enclose everything.’” 35 View of inmate work stations from the platform in Tailor Shop 1 (Inspector General photograph) A necessary step in the new escape planning was for Matt and Sweat to again occupy adjacent cells in the Honor Block. To achieve this, it was necessary for Sweat to regain employment in the tailor shops, as only tailor shop workers were housed on the top tier of Honor Block, where Matt resided. Palmer was instrumental in both Sweat’s return to a tailor shop job and his relocation to a cell next to Matt, thereby, unwittingly, placing Matt and Sweat in position to proceed with their escape plan. After his dismissal from Tailor Shop 1, Sweat had taken a job in the prison library as a clerk and typist, earning the minimum $.26 an hour. Sweat’s library employment continued until January 18, 2015, when, benefiting from Palmer’s advocacy, he was allowed to return to tailor shop employment. According to Palmer, at Matt’s urging, he asked Scott Scholl, the industrial superintendent, to allow Sweat back into the tailor shops. Scholl agreed to the request. Safford testified she was surprised by this action, “because usually once security removes an inmate from Industry, they don’t usually let them go back.” However, Safford stated that Sweat “was an experienced sewer and instructor . . . and all the shops were looking for good sewers.” Sweat had an additional motive for changing jobs: “I wanted to get back. Needed the money.” Most tailor shop jobs pay more than library clerk positions. To prevent renewed contact between Sweat and Mitchell, Scholl assigned Sweat to Tailor Shop 8, the shop farthest from Tailor Shop 1. As a further precaution, the industrial training supervisor in Tailor Shop 8, and her supervisor, the general industrial training supervisor, were under instructions to contact Scholl or Safford if they observed Mitchell in or near that area. 36 These actions notwithstanding, Mitchell found a way to see and speak to Sweat, however fleetingly. According to the general industrial training supervisor, as inmates filed past the Industry Building on their return to the housing blocks at the end of the work day, civilian staff remained inside for their protection. “You don’t want to be out there in the yard if something goes off,” the general industrial training supervisor explained. According to the supervisor, however, Mitchell “would go stand outside.” A correction officer also observed Mitchell in the yard. In that spot, Mitchell could wave to Sweat or exchange a quick greeting with him as he walked by. In addition, according to a civilian employee, Mitchell on one occasion telephoned Tailor Shop 8 asking to speak with Sweat, but was refused. Almost immediately after his re-assignment to the tailor shops, a rumor of an intimate relationship between Sweat and Mitchell re-surfaced. Mitchell said several inmates in Tailor Shop 1 told her of the rumor on January 20, 2015, and two days later she heard the same from Palmer. Fearing, she said, that the rumor placed her in danger with inmates, Mitchell on January 23 filed a complaint with Superintendent Racette, alleging Safford as the source. Sweat also blamed Safford. Rather than handling the matter internally, as with the August 2012 extortion note and the July 2014 anonymous letter, Racette referred Mitchell’s complaint to the DOCCS OSI on February 3, 2015. In its investigation, after both Mitchell and Sweat denied a relationship, and Safford denied spreading a rumor of a relationship, OSI concluded that Mitchell’s allegation was unfounded. However, the investigation failed to interview Trombley, an obviously relevant witness, and failed to search Sweat’s cell, which might have revealed the star-headed security bits and thereby foiled the escape. Within a day of the escape, OSI conducted a follow-up investigation of the matter. Despite acknowledging that the initial investigation was deficient, OSI concluded its follow-up review in only two days and again failed to interview Trombley. Just days after his return to a tailor shop job, Sweat asked to move back into the cell next to Matt. Palmer, again at Matt’s urging, requested the Honor Block housing officer to allow the switch. The request was granted, and on January 24, 2015, Sweat changed cells, moving to cell A6-23, adjacent to Matt in cell A6-22. According to Sweat, the inmate then occupying cell A623 did not want to move, but agreed to do so when Sweat and Matt paid him with approximately $100 worth of cigarettes and “two huge homemade porno books” that Matt had compiled and kept in his cell. When interviewed by the Inspector General, however, the inmate in question 37 stated that neither Sweat nor Matt asked him to move or gave him anything as payment, and he only learned of the move when officers, acting on Palmer’s request, ordered him to change cells. According to an inmate who had worked with Sweat for several years in Industry, Sweat’s return to a tailor shop job and relocation back to a cell next to Matt were highly surprising, given the circumstances of Sweat’s removal from Tailor Shop 1. Attributing these moves to the intervention of Palmer on Sweat’s behalf, the inmate stated: “He had a letter on him written that he might’ve been having sex with an employee in the back room and he was back in another shop in a couple of months. Back in on the block, back in the same cell that he left, exactly the same cell that he moved from. That doesn’t happen for anybody. That’s not an accident.” Mitchell’s First Delivery of Hacksaw Blades As Matt had suggested, Sweat now began thinking about an escape through the subterranean level of the prison, confident he could discover or forge a route to the outside. Sweat’s self-confidence was well-founded, according to an Honor Block inmate who frequently interacted with him. “If he tells you something, that’s what it is . . . he just has a discipline about him that you have no choice but to admire,” the inmate stated. Sweat felt sure that if he could get into the catwalk area behind his cell, he could find a way into the prison tunnels. But to reach the catwalk, he would need to breach the steel rear wall of his cell, and to do that, cutting tools were required. Therefore, in mid-February 2015, he requested through Matt that Mitchell smuggle in hacksaw blades. Mitchell agreed, and for less than $6, she purchased six blades at a Walmart store near her home on February 16, 2015. In an effort to conceal her transaction, Mitchell first purchased a number of household items using her debit card, then immediately after bought the blades with cash at the same register. As with the earlier contraband, front gate officers did not detect the blades when Mitchell carried them into the prison in her bag. According to Mitchell, she placed the blades in the box next to Matt’s work station in Tailor Shop 1. Soon thereafter, Matt had the blades in his cell and he and Sweat divided them, each taking three. Sweat said Matt told him he smuggled the blades from the tailor shop by taping them to his torso, afterward showing Sweat the red marks left on his skin. The tape, Sweat said, came from the shop’s supplies, and he speculated that Matt taped the blades to his side while in the 38 shop bathroom. The Inspector General found that Matt carried the blades to his cell by walking from the shop directly to the Honor Block, or indirectly by way of the infirmary where he requested to be taken for an actual or feigned attack of sciatica. In either instance, Matt would have been in the company of an officer, almost certainly Palmer, the regular Honor Block escort officer. An inmate who worked in Tailor Shop 1 noted that Matt complained of back pain only on days Palmer was working, so that Palmer, not another officer, would escort Matt from the shop. According to the inmate, these escorts became more frequent close to the time of the escape. Indeed, Palmer testified that he escorted Matt from the shop to his cell on a number of occasions, without frisking him on exiting the shop and bypassing the metal detector on the route. Sweat and Matt Cut Through Their Cell Walls After snapping each blade into two pieces, Sweat and Matt set to work cutting into the 3/16-inch-thick steel rear wall of their cells. Using cloth wrapped with rubber bands as makeshift handles for the blades, they cut around a 10-inch-by10-inch air vent located near the bottom right corner of the cell behind their beds. They had taped the bottom ends of the metal bed legs so they wouldn’t make noise when slid aside. Applying a single tooth at the blade tip, the two scratched at a spot on the wall until a hole formed. Once able to insert the blade through the hole, they could begin actual sawing. According to Sweat, he and Matt cut every evening from 6:30 p.m. to 8 p.m., while most other Honor Block inmates were at the mess hall or engaged in recreation on the first-floor “flats.” Sweat said officers did not question why he and Matt remained in their cell during these hours because it had long been their habit to cook their own dinners and paint in their cells. While one cut for 15 or 20 minutes until he tired, the other stood by his cell door with a mirror watching for an officer making rounds. In the event an officer approached, the cutting ceased and they quickly turned to diversionary activities such as listening to a radio on headphones, watching television, painting, or pretending to be asleep. Occupying adjacent cells, as they now did, undoubtedly assisted their efforts. If for example, their cutting was causing too much noise, Sweat said, “[J]ust a quick little knock on the wall and you know you’re getting too loud.” Housing in adjacent cells also positioned them to serve most effectively as lookouts for each other when officers were nearby, and facilitated their passing tools back and forth. Describing 39 the ease with which he and Matt exchanged tools, Sweat stated, “Roll them up in a piece of paper” and “just hand them over.” Sweat stated that the Honor Block afforded a “slight” advantage over other housing units in that the din emanating from inmates’ recreation two floors below covered the sound of the sawing. As Sweat described it, “[Y]ou get more noise, because everybody goes downstairs in their rec areas, and they’d be at the tables down there, card tables, and playing dominoes, and these guys got bad habits of slamming dominoes . . . So, when they’re doing that . . . nobody’s really going to hear you unless they’re your neighbor, and both of our neighbors always went out for rec.” In one instance recalled by Sweat, however, the inmate on the other side of Matt had remained in his cell and heard the cutting. He called out, “What the hell you doing over there?” Matt replied that he was cutting a piece of canvas for a painting, and the inmate didn’t ask again. According to Palmer, he permitted Honor Block inmates to mingle with one another and even enter another inmate’s cell at times. Palmer testified that this occurred when inmates opted not to participate in recreation on the “flats” and remained on their tiers. Asked if inmates were able to enter others’ cells at these times, Palmer testified, “It was frequent through the whole block . . . [where] rules are a little bit more relaxed,” adding that Clinton management was aware of this practice. Sweat estimated that by cutting approximately two inches each evening, he completed a 17-inch-by-12½-inch opening in his cell wall in about three weeks, using a single blade. Matt, less proficient, required an additional week to compete an 18½-inch-by-14½-inch hole, telling Mitchell when he had finished the job. Once completed, Matt and Sweat removed sections of the cell walls containing the air vents with attached ducts. During this time, Sweat claimed, he hid his blades in his locker; Matt secreted his in a bag. After the holes were complete, Matt gave his blades to Sweat “so he didn’t have nothing in there.” As a further precaution, Sweat said, he used magnets he took from a machine in the tailor shop to collect the metal filings produced by his sawing, which he then flushed down his cell toilet. Magnets were found in both Sweat’s and Matt’s cells after their escape. 40 Hole in rear wall of Matt’s cell accessing catwalk. Bed frame is in foreground. (Governor’s Office photograph) In the aftermath of the escape, questions were raised about Sweat’s and Matt’s ability to cut through their cell walls using only a hacksaw blade. To address these concerns, the Inspector General conducted a test utilizing a 3/16-inch-thick steel plate and a hacksaw blade of the type used by Sweat and Matt, and was able to penetrate the steel plate in less than four hours. Holes in Cell Walls Go Undetected Sweat took particular care in masking the hole in his cell wall. After re-inserting the cutout section of steel, he taped over the cut lines and painted the tape to match the color of his cell interior. He was able to do this, Sweat said, because correction officers provided inmates, upon their request, with paint to touch up their cell interiors. Sweat said his cut-out section was so securely replaced and well disguised that he did not fear discovery if his cell was searched. He was less confident about Matt’s work, and said he once told him to improve his “cobble job where he put a bunch of tape and stuff over it . . . I yelled at him . . . made him [do] that again.” 41 Remnants of painted tape used to conceal cuts in Matt’s and Sweat’s cell walls. (State Police photograph) He need not have been worried. On March 21, 2015, as part of Clinton’s random cell search program, security staff purportedly conducted an unannounced search of Matt’s cell that failed to detect the 18½-inch-by-14½-inch wall breach or any contraband. The officer who performed the search stated that while he did not remember this specific search, it was not his practice to inspect the ceilings, walls, vents or toilet areas “unless something pointed me in that direction” during a visual inspection. Sweat and Palmer said they did not recall any such search and expressed doubt that it had actually occurred. Both stated that Matt certainly would have mentioned a search to them, but did not. Further, Palmer testified that officers on occasion would “forge” reports falsely indicating that cell searches had occurred and no contraband uncovered. In addition, weekly inspections of all cells requiring checks of cell integrity from the catwalks, were not done. Unquestionably, thorough searches and inspections would have discovered the holes in both cells and stopped the escape. In another instance, Sweat related, an officer was “messing around” on the catwalk and shining a “big flashlight” on the back of Matt’s cell, yet did not notice the cut. From first breaching his cell wall until the escape – nearly three months – Sweat said he was out of his cell “every single night” with three or four exceptions when relief officers were on duty and “I didn’t know . . . whether or not they’d [do their rounds] or not.” On all other nights, 42 Sweat said, he did not fear his absence would be noticed because, he claimed, officers never conducted required rounds between the 11 p.m. and 5:30 a.m. counts. According to Sweat, he knew when an officer was making his last round for the night: “If they’re walking by, if the guy ain’t got a flashlight, he’s not coming back. If the person, when they’re walking, is only using a flashlight [to read inmate callout slips for the morning] and they’re not looking in your cell at all, they’re not coming back because they’re not interested. They know you’re in there, they figure you’re secure.” Further, on occasions when he and Matt had stayed up into the early morning hours “just painting, just for no reason,” they noticed “a couple of the COs . . . weren’t walking [the rounds].” DOCCS policy requires that officers making rounds must observe “skin and breathing or other movement” for every inmate. Consistent with Sweat’s claim, the Inspector General’s investigation found evidence that many, if not most, night rounds were not conducted at all, or negligently conducted, in the Honor Block. If only one of more than 400 required checks was properly performed during the time Sweat was out of his cell, the escape would have been instantly foiled. Dummy found in Sweat’s cell on the morning of the escape. (State Police photograph) Before exiting his cell each night, Sweat placed a dummy in his bed to deceive officers who might make a round. He fashioned it by stuffing a pair of pants and a hooded sweatshirt. As apparent in the photograph below, although roughly body-like in shape, the dummy lacked 43 any material resembling human flesh, which, as noted, officers conducting rounds are required to observe. Sweat placed the cut-out portion of the wall and its attached air duct in a bin under his bed, and, once out of his cell, reached in from the catwalk and covered the hole with a painting secured by magnets taped to the back of the painting. As evident in the photograph below, the cut-out cell wall section with attached duct is a large object not easily concealed. Cut-out piece of wall and attached air duct in Sweat’s cell. (State Police photograph) “Acting like a Ninja,” Sweat said, he donned the same clothes each night he was out of his cell: his prison-issued green pants, a long-sleeved brown shirt, and a brown tee-shirt he ripped up and wore on his head like a do-rag. “Everything [down] there is dirty and brown, brown and grey in color, so you blend right in,” he said. Around mid-March, when Sweat first crawled from his cell onto the catwalk, he was in familiar surroundings. On at least four occasions since January 2015, including twice during the weeks immediately preceding the escape, Palmer had allowed Sweat onto the catwalk, through a door at the end of the tier, to perform unapproved modifications to the electrical connections for his and other inmates’ cells. The modifications involved re-wiring the cell circuitry to accommodate inmates’ usage of higher-amperage hot plates ˗ a practice prohibited by Clinton policy but long overlooked by officers. Following the escape, Clinton maintenance staff examined the wiring of cells throughout the prison and found that approximately 50 percent of the cells had unauthorized modifications similar to those Sweat performed in the Honor Block. 44 Palmer admitted to the State Police that he allowed Sweat unauthorized access onto the catwalk, and provided him pliers and a screwdriver for this work, which he retrieved when the work was complete. Palmer said that Sweat was on the catwalk for 5-10 minutes each time, not always under visual supervision. Sweat also recalled that he had observed the catwalk space when officers left the doors to the area open. Matt too was familiar with the catwalk area. Incredibly, Palmer testified that around August or September 2014 he had allowed Matt onto the catwalk to hide tubes of contraband oilbased paint he had in his cell. Palmer said he did so “because [Matt] probably wasn’t supposed to have that many paints in his cell,” or have any oil-based paints. According to Palmer, Matt placed the tubes in an approximately 8-inch-by-8-inch cardboard box that they then hid in a recess on the catwalk. Even more troubling, Palmer testified that he did not examine the box containing the paints to determine if Matt had hid other contraband items as well. Palmer said he was able to recall the approximate date of this event because it occurred at about the time concerns were raised about an inappropriate relationship between Sweat and Mitchell as a result of the anonymous inmate note. Concerned that an investigation of the relationship might lead to a search of Sweat’s and Matt’s cells, Palmer was worried that the contraband paints, some of which he had provided to Matt, would be discovered. After two weeks passed without a search, Palmer let Matt back onto the catwalk to retrieve the paints. Catwalk area behind Sweat’s and Matt’s cells with holes visible (Governor’s Office photograph) 45 In effect, Palmer’s actions served to provide warning to Matt of a possible impending cell search. Further, Mitchell testified that Matt told her that Palmer warned him of impending prison lockdowns, which would include cell searches, and removed contraband from his cell. Similarly, an inmate who had been housed on the Honor Block testified that Palmer alerted both Matt and Sweat to impending lockdowns and hid their contraband. According to the inmate, he would thereby learn of upcoming cell searches from Matt. Sweat Begins Search for Escape Route Under Prison The first night Sweat exited his cell, he immediately set to work searching for an escape route. He walked to the far end of the catwalk before climbing down through the narrow space between the catwalk and the cell backs, descending three tiers to the prison’s subterranean level. At the bottom, Sweat found himself in an inch or two of standing water littered with cigarette butts, Styrofoam cups, light bulbs, scraps of paper, plastic bottles, and other detritus discarded by officers from the catwalks or inmates through their cell vents. He then traveled from beneath the Honor Block through a series of 90-degree turns below the laundry building and into the basement of B-Block. He said he was surprised at the relatively free passageways he found. “Nothing ended up being anything like either one of us expected it to be,” Sweat stated, noting that he had anticipated encountering locked doors and gates he would need to dismantle and then re-assemble, using the security bits obtained from Mitchell. Still on that first night, however, Sweat’s progress was halted by a wall between B-Block and C-Block. A cluster of pipes ran through a circular opening in the upper part of the wall, with just enough space for him to slither through, but a steel brace attached to one pipe created an obstruction that would block Matt’s wider girth. Having instructed Matt to measure himself, Sweat carried a tape measure in the tunnels to “make sure fatso could fit” through any opening. Indeed, a tape measure with “National Guard” printed on its case was recovered from the tunnels after the escape. Mitchell testified that she had placed such an item in her desk drawer in Tailor Shop 1, from where Matt retrieved it. 46 The first major obstacle in the tunnels – pipe chase between B-Block and C-Block (OGS photograph) It took Sweat two nights to cut through one end of the obstructing steel brace and bend it out of the way. Immediately on the other side of this opening, Sweat found a steel-edged cement plate in the tunnel floor. Still thinking that a sewer could be a route out of the prison, he hoped the plate covered an opening into the sewer system. Using a hacksaw blade to cut through four bolts fastening the plate to the floor, Sweat was disheartened to discover only “old, rotten boards” and solid concrete underneath. Asked what became of the bolts, Sweat said he “just cut them off and tossed them.” 47 Plate on tunnel floor just inside C-Block. (OGS photograph) In the area just inside the basement level of C-Block, Sweat also first identified a largediameter pipe bearing the letters “LPS” for low-pressure steam. “Oh, this is it. That’s what I was looking for,” he recalled thinking. “I knew steam pipes go out, electricity goes out . . . nothing goes over the wall, so it has to go under.” Following the steam pipe, however, brought Sweat to a formidable obstacle – a brick wall between the basement of C-Block and the Industry Building tunnel through which the steam pipe passed. Breaking through that wall would be extremely difficult, Sweat realized, “so then I went exploring, I wanted to see what the options were. . . .” Over the next several days, Sweat, without a map or blueprint of the prison, traveled the maze of tunnels beneath C-, D-, and E-Blocks, and the prison’s new hospital. As he recounted: “There’s tons of other tunnels throughout the facility that aren’t directly connected to that one or have brick walls already there. Because if you go through there you will see other brick walls, but there weren’t any ways that I thought were conducive to what we were doing. So I didn’t even bother with them. “I searched all underneath that. You know, go down each block, check the backs of the blocks, check each wall . . . get on each side of the steam pipes, so that you could see . . . whether there was another entrance or exit anywhere, before I decided that I was actually going to go through the brick wall.” 48 While lights on the catwalks provided some illumination in the space directly beneath housing blocks, some parts of the tunnels were totally dark. In these unlit areas, Sweat said, he navigated with a small LED light that Mitchell had provided to Matt and that he hung on a lanyard around his neck. “Just enough to see but not enough to be bright if there was somebody at the other end,” Sweat recalled. Sweat said he was careful not to create any unnecessary noise, moving with particular caution when he passed under a catwalk. He said he never encountered anyone in the tunnels, although on several occasions he observed correction officers on the catwalks above him in several housing blocks, but apparently without being seen himself. One night, Sweat said, he was nearly struck by a lit cigarette butt discarded by an officer. Never without a watch, Sweat said he made sure to be back in his cell by 4 a.m. That gave him time to change his clothes, wash himself, reseal the hole in his cell wall, and sleep for a short time before the morning count. Crawling and working on his hands and knees also left him with “bruises and scrapes all over the place . . . it was pretty bad.” Sweat’s inevitable exhaustion did not go unnoticed. Bradley Streeter, Mitchell’s supervisor, seeing Sweat several weeks prior to the escape, thought, “My God, what the hell has happened to him? He looked like he had been wrung through a knothole . . . frail and exhausted . . . not the person I knew.” Mitchell said that Matt too looked tired, and when she asked him about it, he told her he had been “up all night” working below. This was boasting by Matt, who, in Sweat’s account, left his cell to work in the tunnels only twice prior to the escape. Indeed, Sweat had lost a considerable amount of weight, perhaps 30 pounds, working on the escape route. He had also become more fit as a result of “letting myself down and pulling myself back up, you know, three flights every night . . . crawling through all the pipes.” By the time of the escape, Sweat said, he was “probably about the best physical shape I been in.” At Sweat’s urging, Matt had also lost weight. Sweat said that time out of his cell exploring below the prison was an exhilarating experience that gave him a sense of freedom, even during the time an escape route eluded him: “[I]t felt good, because you kind of felt free. You know, you weren’t caged up in the cell no more. Nobody knew where you were. I always left my ID in my cell, you know, when I left the cell, so I didn’t feel like I was an inmate anymore. It gave me that little feel of freedom because whenever I left my cell, on a normal basis, I always had my ID. And it was different for me, you know, after 14 years, or 13, or whatever it’s been. It was something new, it was doing something that I could actually use my mind for, that I could apply myself to.” 49 Breaching the Brick Wall Having discovered no viable alternate route in his exploration of the tunnels, Sweat settled on attempting to breach the brick wall separating C-Block and the Industry Building tunnel. In approximately late-March he began “scraping” and “picking” at the bricks above the steam pipe, aided by tools he fashioned from “things I found that were down there that maintenance workers left around.” With a hacksaw blade he shaped a length of steel into a makeshift pry bar and sharpened a foot-long, inch-thick bolt to form a pick-like implement. But even with these tools, progress was laborious and slow. “I was having a hell of a time,” Sweat said. He said he was able to remove only three or four bricks a night from the three-layer-thick wall, and “[b]ecause [of] fat-ass Matt . . . [I] had to take out a couple of extra bricks.” The work was further slowed by Sweat’s precaution of replacing the bricks every night before returning to his cell. As he worked, Sweat stacked the removed bricks behind him on the steam pipe and another large pipe ˗ bricks from the exterior side of the wall on one pipe, those from the interior side, which were different in size and color, on the other. This made it easier, Sweat said, to replace the bricks in their original positions, “so that if somebody come over and look with a flashlight, you couldn’t tell the difference.” Breach in wall between C-Block and Industry Building tunnel with removed bricks on pipes. (State Police photograph) 50 In fact, Sweat had little reason to worry that his handiwork would be discovered by prison staff. Soon after assuming his position in April 2014, Clinton First Deputy Superintendent Donald Quinn had implemented what he said were “quarterly” inspections of the tunnels beneath the main prison and annex. However, the newly ordered inspections were not performed quarterly, but only twice yearly, and alternated between the main prison and annex. Thus, the main prison tunnels had only been inspected in September 2014, and would likely not be inspected again until months after the escape. Sweat testified that he was “not worried about” tunnel inspections, “because they’re lazy, to be honest.” Sweat added, “You could tell that nobody had gone down there in, looked like, forever, because they had thick layers of dirt and dust and stuff on the floor.” The work of breaching the brick wall became easier when, in early April, Sweat serendipitously came upon an eight-pound sledge hammer that, in violation of policy, had been left unsecured beside a locked contractor’s “gang box” in the tunnel near E-Block. Sweat said several shovels and a rake were also outside the box. Sweat recalled his reaction to finding the hammer: “Oh, man, I couldn’t have asked for anything better.” Eight-pound sledge hammer Sweat found next to “gang box” in tunnel. (State Police photograph) 51 Working at the wall with the sledge hammer, makeshift pry bar, and pick, Sweat said he timed his blows to coincide with the loud sounds from pipes that “bang like a son of a bitch down there . . . So I wait until they start banging, and then I would bang.” In this manner, Sweat recalled, after about two weeks “I knocked the wall out.” Sweat Reaches the Inside of the Prison’s Main Wall In late April, after completing a hole in the brick wall large enough for Matt and himself, Sweat continued to follow the route of the steam pipe, making a series of 90-degree, left and right turns. This brought him to his greatest obstacle – the seven-foot-thick, below-ground base of the perimeter wall of the prison. “Son of a bitch,” Sweat recalled, “this concrete wall.” From observations he had made while working in the Industry Building, Sweat surmised, correctly, that the steam pipe, after passing through the wall, continued underground to the power plant a quarter mile south of the prison. However, as the steam pipe was still active, Sweat understood that penetrating it as a means of getting through the wall was not feasible. He also ruled out trying to burrow under the wall for two reasons: One, there was standing water in the area and “I didn’t want to go swimming;” and two, “I figured if you’ve got that much wall and you’re already standing on a cement slab, the chances are that wall probably still goes down a couple of more feet . . . and knowing that it’s sitting on a mountain . . . it’s all rock, I’m pretty sure that they blasted rock away to put that wall in. . . .” Therefore, he turned his attention to the wall itself and, working in the cramped, dark space, began chipping away the concrete with the sledge hammer and sharpened bolt. This work proved inefficient and exhausting -- “[t]he sledge hammer was killing me because it was an eight-pound sledge hammer . . . banging on that wall was a bitch.” To protect his hands, he wore heavy-duty work gloves purchased and smuggled in by Mitchell. In early May, according to Sweat, Matt joined him below on two consecutive nights – the only times Matt descended into the tunnels prior to the escape. As Sweat recalled: “[I]t had been like four months and he’s . . . complaining when I come back because I don’t want to talk. I’m tired, I’m working my ass off, I’m sweating . . . I gotta wash up and everything before the CO does his rounds, get everything back in place and taped up and painted. So I’m like, ‘Alright, I’m gonna take you.’” 52 Climbing out of his cell and through the various openings in the route, Matt “couldn’t believe” what Sweat had accomplished. “He’s like, ‘Oh, man, I would have gave up a long time ago,” Sweat said. Sweat himself acknowledged “[t]here was a couple of times . . . I got quite discouraged.” But he understood that having started on the escape route, there was no turning back. As he said, “[W]e just kept going because you can’t stop . . . What the hell were you going to do . . . just go tell them, ‘Hey, excuse me, officer, I cut a hole in the back of my cell?’” On the first night the two were in the tunnels together, Sweat and Matt removed a metal sleeve that lined the opening in the pipe chase between B-Block and C-Block and carried it to the main wall. There, Sweat flattened the sleeve so he could use it to cover the hole he was chipping in the wall in the event a prison worker entered or looked into the area. At the wall, Sweat and Matt were humorously reminded of Andy Dufresne, the main character in the popular prison escape film “The Shawshank Redemption.” According to Sweat, “We were laughing and joking about how Andy did it in 20 years; I think we might be able to do it in 10.” Sweat also recalled a comical ending to one of Matt’s excursions below the prison: “So we’re sitting on the pipes, I’m pulling my boots off, he goes ‘What are you doing.’ I said ‘Cleaning my boots off.’ I said, ‘You’re cleaning yours off, too.’ He says, ‘Do you do this every night?’ I said, ‘Yeah.’ I said, ‘Take one of them washers . . . pull all the gunk out of your boot, and then take your glove off and wipe the bottom of your boots off.’ He said, ‘I’m not doing that,’ and I said, ‘Bullshit.’ I said, ‘You’re wiping your boot off because you’re stepping on my back, there ain’t no way you’re stepping on my back with a dirty-ass boot.’ So I ended up helping him up and . . . the first [tier] you go up is really tight for him, so he was fidgeting to get his chest through and then, you know, he’s got a gut, so when he finally got his . . . I’m already up, you know, he’s downstairs, he’s standing on a pipe coming up. I’m already up on the first [tier] and his gut plops over the catwalk and he’s stuck. It looks like he’s stuck there like a half a man with a gut hanging out, and I’m laughing my ass off, in the middle of this. And he’s like, ‘What’s so funny, man?’ I said, ‘The way your fucking gut’s hanging out.’ That was kind of funny. I helped him up.” The second night Matt joined Sweat below, they went to the gang box, and Sweat, using tweezers and a paperclip, picked the lock. Inside, Sweat said, they found bolts and screws, but no tool that would be of use to them. 53 Contractor’s gang box in which Sweat found tools, with lock at upper left. (State Police photograph) Back at the wall that same night, Sweat, using the Tweezers, unscrewed the plate covering an electrical junction on the wall and wired in an extension cord he purchased in the prison commissary. As the area was uncomfortably hot from the steam pipe’s radiant heat, Sweat connected an “old” fan of the type commonly found in inmate’s cells. For lighting, Sweat connected a second extension cord with an attached work light that he had found in his explorations of the tunnels. He explained he found the extension cord and light “where they put in a new boiler, either for the bath house or for the laundry, and they left it there . . . so I just took it and figured that they'd think they . . . misplaced [it], or something.” The electric light supplemented the LED lamp Sweat had been using and which “burn[ed] through a lot of batteries” – by that time a total of four packs of batteries that had been purchased in the commissary. 54 Extension cord with work light and jury-rigged electrical connection. (State Police and OGS photographs) In the days that followed, Sweat said, Matt asked to be taken into the tunnels several more times. But Sweat declined, telling Matt, “I’m not taking you down till I’m done ‘cause it’s too much work and I don’t get nothing done.” Seeking additional tools, Sweat said, he returned to the gang box, picked the lock, and was pleased to now find many useful items, including three power drills, an angle grinder and spare grinding disks, rechargeable battery packs, disposable breathing masks, an LED light on a headband light, a steel punch, and a two-pound sledge hammer. Sweat said he took the hammer, thinking, “perfect, a baby sledge hammer,” as well as the punch, two breathing masks, and the light. Sweat said he ignored the drills because they were no use without concrete bits. Sweat stated that each morning before returning to his cell, he replaced the two-pound sledge hammer in the box, which he re-locked. On successive nights and mornings, he repeated these actions. Notably, Sweat never returned the eight-pound sledge hammer he had found earlier beside the box, nor the light and masks he found inside the box. In addition, he said he broke and discarded the steel punch. Within a few days, he said, he noticed a new punch in the tool box, but thought it wise not to use it. Clinton records do not show that prison security staff or the contractor ever reported any missing tools or other items. 55 Resuming work at the wall with the hammer and punch, Sweat said he still was able to only make scant headway, toiling in the intense heat from the nearby steam pipe. Chipping away several inches of concrete exposed a number of bore holes, each several inches in diameter, which Sweat surmised had been drilled as integrity tests at an earlier time. The Inspector General interviewed DOCCS staff and reviewed construction and maintenance records related to the prison wall, but was unable to determine the origin of the holes. Lacking concrete bits needed for the power drill, Sweat requested from Mitchell, through Matt, two such bits, as well as two chisels and a steel punch. As with his previous requests of Mitchell, he received the items within several days. According to Mitchell, Matt had devised a clever, arguably safer scheme for smuggling in these tools. Following this plan, Mitchell purchased the tools as well as two pounds of ground beef. Once home, she slid the items into the meat and froze the package. The following morning, she carried the tool-laden, frozen meat in her bag through the prison’s front gate without detection. That same morning, Matt brought from his cell to the tailor shop two aluminum tubes of paint which he placed in Mitchell’s desk drawer. Matt did not pass through a metal detector and was not frisked on his walk to the tailor shop, and his actions apparently went unnoticed by both the officer escorting him and the officer responsible for security in the shop. According to Mitchell, Matt had asked Palmer to retrieve the meat and paint from Mitchell in the shop and deliver them to Matt’s cell. Mitchell testified that Palmer arrived in the shop later that day and, consistent with Matt’s request, picked up the package of meat and the paint tubes, placing them in a large manila envelope. Mitchell further testified it was her understanding that the paint tubes would serve as a decoy in the event that the envelope went through a metal detector while being carried by Palmer to the Honor Block. As Mitchell stated, “If [the metal detector] rang . . . it was the paints went off.” This precaution seems superfluous, as it is common knowledge that officers and packages in their possession are not subject to metal detector scans inside the prison. Although Palmer testified that he did not recall this delivery of meat, the Inspector General obtained no facts contradicting Mitchell’s account. Indeed, Palmer acknowledged in his testimony that he was the “go-to guy” for Matt and his only “handler” for the exchange of favors. Sweat testified that he and Matt received “that first thing of hamburger with two chisels, two concrete drill bits, and a punch” in late April or early May 2015. He recalled the package 56 appeared “larger” than two pounds of meat because Mitchell “took it apart to put [the tools] in there and . . . didn't pack it tight.” Now in possession of chisels and another punch, Sweat returned to the arduous task of attempting to chip a hole through the thick outer wall of the prison. With the bits necessary for drilling into the concrete wall also in hand, Sweat returned to the gang box for the contractor’s power drill, but was dismayed to find that the drill was no longer in the box. Soon thereafter, Sweat discovered that the box had been removed. Indeed, consistent with Sweat’s recollection, Clinton records show that the contractor removed the box on April 27, 2015. Sweat then resumed the slow work of chipping at the wall with hand tools. Making little progress in this manner at the wall, Sweat again benefited from unexpected help. On May 4, 2015, Clinton maintenance staff shut down the prison’s steam heating system for the season, and about a week later, Sweat, having worked every night, noticed that the air around him had grown cooler. Placing his hand on the steam pipe, “I realized it’s cold.” He then “tapped on it and I could tell there was no water in it. Fuck it, if they drained that pipe and it’s empty, I might be able to cut into that and go through that and cut my way back out.” At first, Sweat considered breaking a hole in the pipe by striking it with the sledge hammer and chisels or punch. Here he again recalled “The Shawshank Redemption,” specifically the scene in which the protagonist “hit [the sewer pipe] with the rock, and he broke the pipe to climb into the shit tube to get out.” However, when Sweat tested this technique on the steam pipe, he immediately knew it was a mistake. As he recalled: “So I tapped it with the sledgehammer. Man, you could hear that fucking thing go all the way down to the power house, all the way the other way, and come all the way back. It was really loud, it echoed the whole way. I said, ‘I can’t do that, it’s way too loud,’ and I wasn’t even hitting it, it was just tap, tap, and that was too loud.” Sweat concluded, therefore, he had no choice but to cut holes in the steam pipe with hacksaw blades. 57 Chisels, punch, hacksaw blade pieces, and unused drill bits left by Sweat in tunnel. (State Police photographs) Sweat now was confident he was facing the final serious obstacle to his escape, and that he had in hand the means through it. Contemplating breaching and squeezing through the pipe rather than digging through or under the wall, Sweat thought, “It’s not going to be comfortable. But it’s faster.” Mitchell Smuggles in More Tools and Joins Plan to Leave with Matt and Sweat In the four months preceding the escape, Sweat and Matt drew Mitchell more deeply into their plot. Aware of the escape plan since the beginning, Mitchell provided further help by smuggling additional escape tools and other contraband into the prison at Sweat’s and Matt’s request. Before long, she agreed to join them after the breakout. Soon after deciding that he and Matt would try to escape, Sweat set about manipulating what he knew were Mitchell’s feelings for him. At this time, Mitchell recalled, Matt asked her, “What would you do if Sweat were to grab and kissed [you], would you [tell] anybody?” By answering, “Probably not,” Mitchell understood she was revealing her openness to an intimate relationship with Sweat. Soon thereafter, Sweat began sending notes to Mitchell through Matt, some instructing her about tools needed in the escape plan, others of an explicitly romantic or sexual nature. In the notes, Mitchell recalled, Sweat “was telling me that he loved me and that 58 he wanted to spend his life with me.” “[H]e’s like, ‘I love you, can’t wait to get you in my arms, make love to you all night long.’” Mitchell admitted that in her notes she was “saying those things back,” seduced in part by her believing that “a younger guy would actually like an older woman.” Mitchell incredibly claimed to investigators that when she was writing notes of a sexual nature to Sweat, she was “thinking of my husband.” Sweat said he wrote Mitchell “love lust” notes merely to “placate her.” Sweat said he wrote his notes on post-it size slips of paper, which he folded as small as possible and handed to Matt in the morning. According to Mitchell, Matt delivered the neardaily notes to her by slipping them into her desk drawer while he stood at the platform in Tailor Shop 1. She said she wrote a response to every note, which she either handed to Matt or Matt retrieved from her drawer, to take to Sweat. At least some of these exchanges were noticed by an inmate who testified he saw Matt “going up the desk, reach in, and grab shit out.” Both Mitchell and Sweat said they destroyed all the notes immediately after reading them. “Never keep notes,” Sweat told investigators. Tailor Shop 1 platform with civilian employee’s station at far end. (Inspector General photograph) Mitchell made little attempt to hide other interactions with Matt, admitting she was at his work station or talking with him elsewhere in the shop for “30 minutes” each day. That is an underestimate, according to an inmate who observed Mitchell’s and Matt’s interactions and commented, “It would blow me away . . . she would go over to his machine every day and would spend . . . 85 percent of the time at his machine,” even ordering the inmate who sat next to Matt 59 to move so that she could sit there. Matt, the inmate added, “never seemed to do much work because he was especially chummy” with Mitchell . . . I had never seen anything like it.” Another inmate had a similar observation, recalling that Mitchell was “bent over in front of [Matt] . . . she would literally stand in front of the fucking guy’s machine all day.” The two inmates described Trombley, the correction officer assigned to the shop, as negligent. As one of the inmates testified, “The officer was sitting up there all the time, watching this whole thing. It was just amazing. I would shake my head.” According to the second inmate’s testimony, Trombley spent considerable time every day reading “books, novels.” A third inmate testified, “A lot of times, Officer Trombley would, every day he’d have a different book or magazine.” Trombley’s blatant disregard of his duties was noticed by civilian staff as well. When Trombley worked as a relief officer in Tailor Shop 2, according to the industrial training supervisor in that shop, he sat at his desk reading most of the day. Mitchell and Matt Have Sexual Encounters in the Shop Matt, as Sweat had earlier, told Mitchell he had romantic feelings for her. Mitchell testified that Matt told her, “You know I love you.” Over time, Mitchell’s and Matt’s relationship turned sexual. According to Mitchell, one day while she and Matt were alone in the adjoining Tailor Shop 9 to retrieve a machine part, “Matt grabbed me . . . and he kissed me . . . I was scared shitless. . . .” Asked by a State Police investigator, “Scared but excited?” Mitchell responded, “Yeah.” Mitchell claimed that while the encounter meant nothing to her, Matt might have seen it differently. “What makes it a relationship in his [opinion]?” the State Police investigator asked. “Maybe because I didn’t go to anybody and say anything,” Mitchell answered. Mitchell admitted that a second sexual encounter occurred in Tailor Shop 9 not long after the first. In that shop again to retrieve a part, Mitchell stated, she performed oral sex on Matt. While Mitchell stated that only two incidents of sexual contact occurred in Tailor Shop 9, an inmate testified that Matt and Mitchell entered Tailor Shop 9 for sexual encounters “six, seven, eight times.” According to the inmate, Matt, referring to Mitchell, said, “I’m gonna get that . . . I’m gonna take her in the room, we already talked about it, she’s saying I can, I gotta be quick.” The inmate said Matt asked him to serve as a lookout, and when Matt and Mitchell emerged from Tailor Shop 9, Matt placed his fingers under the inmate’s nose, saying, “Here, smell this.” 60 In fact, Mitchell herself admitted further sexual contact with Matt after the incidents in Tailor Shop 9. Almost “daily,” she testified, Matt stood by her desk and asked her to fondle his penis by reaching into his pants through a hole he had cut in his prison clothing. “He wanted me to tell him how much I wanted it and how much I liked it. It’s like he needed his ego fixed or something.” Mitchell said she fondled Matt on a number of occasions, but refused other times. Several times, according to Mitchell, Matt also followed her to her locker in the shop and asked to see or touch her breasts. She said she refused. Another inmate account of an incident at Mitchell’s locker contradicts her claim. This inmate testified he witnessed Matt placing his hand between Mitchell’s legs, and that she didn’t appear to resist. This inmate also said Mitchell allowed Matt to keep his headphones and other personal items in her locker, and that Matt retrieved items from the locker each day. In April or May 2015, Mitchell said, she took photographs of her naked body at home. After making prints on her home printer, she took copies into the tailor shop for Matt and Sweat. Mitchell said she took the pictures at Matt’s request, whereas Sweat said Matt told him they were Mitchell’s idea. Around this same time, coworkers, both civilian and security, noticed that Mitchell’s appearance and dress began to change. Mitchell admitted she had begun dieting and dressing more attractively, but claimed it was so she would look better for her husband. During this period, Matt and Sweat asked Mitchell for further assistance in the escape plot, which she willingly provided. Eventually, Mitchell said, she decided she would join Sweat and Matt after their breakout, agreeing to meet them in her vehicle and drive away with them. Sweat and Matt “zoned in on my unhappiness,” Mitchell testified, until she became “caught up in the fantasy . . . of a different life.” Matt kept Mitchell informed about Sweat’s progress beneath the prison, and, in addition to smuggling in tools, Mitchell began to assemble equipment and other items they would need after the escape and which she planned to have in her vehicle when she picked them up. She purchased a pair of black cargo pants Sweat had specifically requested, and on April 2, as evidenced by a sales receipt obtained by the Inspector General, she bought a compass. Other equipment needed for life on the run – a tent, sleeping bags, fishing poles, a hatchet, a rifle, a shotgun, and ammunition – she or her husband already owned. Mitchell testified that Matt had told her that he intended to cut down the barrel of the shotgun. According to Sweat, Mitchell had purchased additional hacksaw blades for this purpose, which she kept under the seat of her 61 vehicle. In fact, Mitchell had used her debit card to purchase two hacksaw blades from a local store on May 17. In mid-April, Sweat requested from Mitchell maps for their post-escape flight. Mitchell thought maps were unnecessary as her vehicle was equipped with a GPS, but Sweat wanted a back-up plan. Mitchell then purchased a United States road atlas and smuggled it into the prison, contrary to prison policy prohibiting maps. Mitchell said she handed the atlas to Matt, who examined it at his work station in the shop for five or 10 minutes. Worried that the spiral binding of the atlas would set off the metal detector on the return to the Honor Block, Matt asked Mitchell to photocopy four pages of maps of sections of New York State. Sweat said he believed Mitchell made the copies in the prison. Mitchell gave the copies to Matt, who carried them to his cell and handed them to Sweat. The copies didn’t fully satisfy Sweat, who told Matt he should have brought the entire atlas so they would have more than just New York State maps. When Matt explained his concern that the binding could be detected, Sweat replied, “So take the damn spiral out and put some thread through it.” Asked if Matt had viewed the atlas in the tailor shop, Sweat responded, Matt “wouldn’t know how to find a fucking place on there anyway.” Sweat said he taped the pages together to create a map of the entire state. Atlas from which Mitchell copied pages, left, and Sweat’s composite map of New York State. (State Police photographs) Planning their getaway, Mitchell made several calls from her home looking for cabins to rent in Vermont, a possible destination mentioned by Matt. According to Mitchell, it was Matt’s 62 idea, which she rejected, that he and she would check in as husband and wife, with Sweat posing as their nephew. As it turned out, she recalled, all the cabins she inquired about were too expensive. Finally, Mitchell said, Matt focused on Mexico as their ultimate destination. Matt had served time in a Mexican prison and, according to Sweat, claimed to have connections to a Mexican drug cartel. Sweat also believed Matt’s ability to speak Spanish and his complexion would help him pass as Hispanic. Asked by an investigator if he himself speaks Spanish, Sweat replied, “Not a lick . . . So I needed him as much as he needed me.” A warmer climate also apparently appealed to Sweat. In a note he sent to Mitchell, she recalled, “He said something about wanting to be where it was warm and he could scuba dive.” Sweat, in his testimony, recalled writing such a note, but said it was only intended to exploit Mitchell’s feelings for him. He stated, “[B]ecause she was so infatuated, [Matt and I] played off that . . . ‘Yeah, we’ll be together, it’ll be great . . . we’ll go down to Mexico and we’ll get a nice place by the beach,’ and I just kept placating that.” Mitchell said she cannot swim. Sweat said he and Matt had come up with names they would assume after reaching Mexico. Sweat would become “James Tuttle . . . after my uncle.” Matt would take the name “Tony Goya,” possibly reflecting his partial Italian ancestry and intended persona. The choice amused Sweat, who told Matt, “Yeah, that sounds like an Italian Mexican.” Although she engaged in sexual activity with Matt, Mitchell claimed, “I care more about Sweat.” She said the future life she envisioned with Sweat did not include Matt, with whom she “would only be buddies.” As Mitchell stated, “After it quieted down . . . Matt would go off by himself and . . . Sweat and I would be together.” Needless to say, Sweat saw things differently. He said his communications with Mitchell were calculated only to ensure she would appear at the post-escape rendezvous in her vehicle. “I just wanted a ride,” he said. At Matt’s request, Mitchell also smuggled in items not essential to the escape, including Bacardi 151 and Wild Turkey she had poured into plastic water bottles. An inmate testified that Matt shared the alcohol in the shop with other inmates. Mitchell said Matt told her that he occasionally drank alcohol with Palmer. Palmer testified that although he never drank alcohol with Matt, he once smelled it on Matt’s breath, but took no action. An inmate stated that on a weekly basis Mitchell brought Matt food and other items, including, on seven or eight occasions, envelopes that Matt said contained paint and brushes he could not order and receive through the 63 prison package room. Sweat said he reprimanded Matt for making unnecessary requests that only increased the risk that Mitchell would get caught and the plan revealed. In late May, according to Sweat, Lyle Mitchell again became worried when he discovered that Joyce Mitchell was still smuggling contraband into the shop. Sweat said Lyle Mitchell approached him and said, “She’s bringing all that stuff in, and I want to make sure nobody’s putting pressure on her, you know, trying to extort her for stuff.” Concerned that Lyle Mitchell’s curiosity could expose the escape plan, Sweat said he and Matt crafted a suitable explanation involving the painting Joyce Mitchell had asked Matt to make for her months earlier, but which, according to Sweat, had not even been started: “The next day when I talked to Lyle, I told Lyle, I said, ‘Listen, I talked to Matt, and you didn’t hear this from me because you’re not supposed to know, but the reason she’s bringing stuff in, I guess you’ve got a birthday or an anniversary or something coming up? And, I guess he’s making something for you? She’s got him making something for you, or something for that.’ I said, ‘You didn’t hear that from me.’ I said, ‘That’s where the stuff is going.’ So, that was what [I] told him. He was fine with that.” Ironically, Mitchell testified that she had to “draw the line somewhere,” and refused Matt’s requests to smuggle a handgun, micro-knife, and cellphone into the prison. In his testimony, however, Sweat contradicted Mitchell, stating “she was all for” bringing in a handgun, but that he dissuaded her. According to Sweat, “She had actually said that she could get [handguns] from her brother, but I said, ‘No, we don’t need none. We don’t need guns in here. There’s no reason to have a gun.’ But she was going to bring a rifle and a shotgun when she come to pick us up.” In addition, Sweat said he and Matt had discussed obtaining a cellphone, but believed it could be detected if used in the prison. “So, play it safe,” Sweat recalled, “Don’t even bother asking for something like that . . . it’s not necessary.” Mitchell and Matt Discuss Murdering Mitchell’s Husband A grim new element entered the plan when Mitchell and Matt began discussing the possibility of murdering Mitchell’s husband, Lyle Mitchell. Sweat said the idea was Mitchell’s, and was first expressed when she openly talked in the shop about her husband. Recalling what Matt had told him, Sweat stated, “For whatever reason, she was pissed off, and she goes, ‘Oh, pop my husband, he’s worth more to me dead than he is alive.’” Sweat also stated that in notes Mitchell sent him at this time, she said she hated her husband. Further, according to Sweat, “She 64 wrote . . . ‘Oh, you guys gotta get rid of the glitch’ . . . she kept calling him the glitch,” a term Sweat said Matt might have first used in reference to Lyle Mitchell. Referring to Lyle Mitchell’s murder, Sweat stated, Mitchell “was trying to get us to do it before we leave . . . but I finagled it to tell her we’ll do it afterwards . . . just so she would keep giving us what we needed and not say nothing.” Mitchell’s plan, according to Sweat, was to administer sedatives to her husband and “drive him off a cliff somewhere.” Sweat testified that Mitchell told him that she had searched the local area but couldn’t find a suitable cliff. Sweat said he never planned to kill Lyle Mitchell, and that Matt was “playing her too. He wasn’t going to kill him. He told me he wasn’t.” Mitchell provided a different account of these conversations. She admitted that she had made remarks in the tailor shop about her husband, but claimed they were in jest. According to Mitchell, “I was being a smart aleck. Every husband and wife have arguments and say, ‘I can just kill him,’ you know? Every couple does that. I didn’t mean anything by it.” She claimed that it was Matt’s idea to murder her husband, and that she pretended to agree to the plan out of fear that Matt would kill her husband, either inside or out of the prison. It is undeniable, however, that by abetting Matt’s and Sweat’s escape from the prison, she was furthering a plan that, as she herself admitted, included Lyle Mitchell’s murder. Moreover, despite her claims to the contrary, Mitchell took steps consistent with a plan to murder Lyle Mitchell. Within days of the escape, Mitchell admitted, she accepted from Matt “two pills” which she assumed were painkillers prison medical staff had prescribed him for his sciatica. The plan, according to Mitchell, was that on the night of the escape, she would surreptitiously administer the pills to her husband to put him into a sound sleep, pick up Matt and Sweat outside the prison, then return home where Matt would murder Lyle Mitchell. Mitchell said she took the pills home the same day Matt gave them to her and kept them in her purse. Incredibly, in her testimony to the Inspector General, Mitchell claimed to have forgotten she had the pills and, only after the escape, flushed them down the toilet. However, Mitchell, in two separate statements to the State Police, claimed she had never received the pills from Matt. Sweat and Mitchell told investigators that the plan was for Mitchell to pick them up in her vehicle outside the prison at midnight. Sweat said they intended to drive all night, reaching West Virginia, where they would hide out for a while before slowly making their way to Mexico. According to Sweat, he and Matt had considered several options for dealing with Mitchell’s 65 presence after the escape. One option, he said, was for Mitchell to drive them to her home, where she and her husband, already drugged, would be tied up. Matt and Sweat then would take food from the house and drive away. Another possibility, according to Sweat, would be to drive away after the midnight rendezvous, leave Mitchell tied up somewhere, then a day later report her whereabouts. Sweat said that Mitchell herself suggested yet another possibility ˗ she would drive the escapees “as far as I can and drop you off.” Sweat said he rejected this idea because he feared Mitchell might change her mind once they separated and turn them in. Asked by investigators if they planned to murder Mitchell after their getaway, Sweat said he never considered it, but that he didn’t know what Matt might have done. Near the end of May, Mitchell said, Matt told her that Sweat was close to completing his work in the tunnels and the escape could occur any day. When asked for assurance she would meet them with her vehicle as planned, Mitchell, according to Sweat, told Matt: “I’ll be there, I’ll be there. I haven’t failed you guys yet.” Matt Seeks Mitchell’s Help in Retrieving a Package from Outside the Prison As the escape neared, Matt enlisted Mitchell’s help in his attempt to obtain a package from outside the prison. According to Mitchell, on May 12, 2015, Matt requested she call a telephone number he provided, ask for “Diane or Diana,” and then “act like I work at a doctor’s office and say, ‘I would like to confirm a doctor’s appointment on Saturday or Sunday at 4 p.m. at Alice Hyde Hospital.’” This cryptic message, Mitchell testified, would set in motion the prearranged delivery of a package to Mitchell in the hospital’s parking lot at the time noted. Mitchell was then to smuggle the package into the prison and give it to Matt. In her testimony, Mitchell provided various descriptions of the contents of the package. In one version, Mitchell testified that she assumed the package would hold “pills . . . [from] a registered nurse,” who, Matt said, wanted the items “out of [the nurse’s house] because she was nervous.” Mitchell further noted that Matt “never actually said [what the package would hold], but seeing I was supposed to be giving my husband two pills that would knock him out, I want to say it was pills.” In another, Mitchell said that Matt told her the package would also contain $500, of which she was to deliver $200 to Matt and keep $300 for herself. In either scenario, Mitchell said, the package would resemble a Lean Cuisine frozen meal, which she could smuggle into the prison with her personal items. Mitchell noted the ease with which this 66 could be accomplished: “Because I eat Lean Cuisines and frozen things, just carry it in with those.” According to Mitchell, at Matt’s urging, she called the provided telephone number repeatedly in the evening after work in mid-May 2015. On some occasions, Mitchell said, there was no answer, the telephone transferred to a generic voicemail recording, and she did not leave a message. On others, she claimed, she hung up out of fear before someone answered or refused to answer a return call because she “was nervous.” Around the same time, Mitchell testified, a male answered the telephone but replied that there was no Diane or Diana at that number. Mitchell said that when she told Matt of this incident he requested she call the same number, but this time ask for “Bree.” Mitchell did so, she testified, and a female who answered the telephone replied, “This is Bree.” After reciting her scripted lines about a hospital appointment, Bree responded “okay,” but provided no further details of the package transfer and the call was ended. Mitchell also reported this to Matt, who stated that she had neglected to tell Bree her vehicle’s make and model, so that Bree would know whom to approach for the hand-off of the package in the hospital parking lot. Once again Matt requested that Mitchell call Bree, provide a description of her vehicle, and obtain the package. This time, according to Mitchell, she told Matt she did not feel “comfortable” doing this and would not call again. On June 3, Mitchell said, when Matt renewed his request, she relented and called the telephone number several times that day and the next day According to Mitchell, no one answered the telephone and the hospital rendezvous did not take place. Unconvincingly, and despite the aforementioned acts in furtherance of this scheme, Mitchell testified she had no intention of meeting anyone at Alice Hyde Hospital or retrieving a package and delivering it to Matt. Notably, Mitchell’s telephone records reveal that after her call to “Bree” on Thursday, June 4, the night before the Friday escape, the recipient of Mitchell’s call immediately telephoned Mitchell back. When interviewed by the State Police, this individual, the wife of a Clinton inmate, confirmed the receipt of “crazy” telephone calls from a woman “calling to confirm an appointment on Saturday or Sunday,” but denied any part in aiding the prison escape or smuggling drugs into the prison. 67 Sweat Cuts into the Steam Pipe Using the hacksaw blades remaining from the February delivery, Sweat turned his attention to cutting into the steam pipe. From measurement markings on the pipe, Sweat knew the section nearest the wall to be 18 inches in diameter. Assuming the pipe wall’s thickness to be 1/2-inch (it is actually 3/8-inch), Sweat concluded that the pipe’s inside diameter of 17 inches was wide enough for he and Matt to squeeze through. “I figure I got him through a 16-inch wall, he should be able to fit through [the steam pipe] . . . I knew that if I got into the 17-inch area, I would still be able to move around a little bit, just enough to be able to cut my way out,” Sweat said. With these calculations in mind, Sweat cut through the outer fiberglass sheathing and began sawing into the pipe’s convex surface. Progress was swift, he said, because he could work for a “couple of hours” without interruption as “I didn’t really have to worry about noise.” In addition, he said, “By then . . . my endurance for the movement, cutting, was already high from cutting holes, so I was able to work longer periods of time.” Cutting as much as 10 inches a night, he said, the entry hole took less than a week to complete. Entry hole in the steam pipe just inside the prison wall (OGS photograph) 68 While cutting the entry hole into the steam pipe, Sweat realized that he needed to replenish his stock of hacksaw blades to finish cutting into and out of the steam pipe, as well as getting past possible further obstacles. As before, he requested through Matt that Mitchell smuggle in more hacksaw blades. According to Mitchell, she employed the same scheme as utilized in the earlier tool delivery. Again purchasing two pounds of hamburger meat, she unwrapped the meat, inserted two hacksaw blades she had broken in half, then re-wrapped and froze the package. On or about Friday, May 29, Mitchell smuggled the frozen meat containing the blades through the prison’s front gate and into the tailor shop. In the shop, Mitchell testified, she placed the meat in a bag along with two aluminum tubes of paint Matt had given her. She then put the bag in the freezer section of the shop refrigerator. Palmer testified that Mitchell summoned him to the tailor shop that Friday and asked him to deliver the bag to Matt. Opening the bag, which was made of green fabric used in the shop, Palmer observed “two tubes of white paint, and then there’s a pound of hamburger.” Palmer said he advised Mitchell, “Tillie, don’t be doing this. If [Matt] needs something, he’ll go through me.” The Inspector General further questioned Palmer about this delivery: Q: Okay, did she say why she was giving Matt meat? A: No. Q: Did you ask her why she was giving Matt meat? A: No. Q: Did this seem unusual to you? A: I knew we were in a gray area with the meat. Q: But not something so gray that you wouldn’t question her? A: No, because [Matt] had helped out in the shop. *** Q: Okay, but she didn’t tell you the reason why she was giving Matt a big chunk of meat? A: No. Q: And you didn’t ask her? A: No. I just told her don’t be doing that. What you’re doing is wrong. If you need something, go through me. Q: And so why did you instruct her? A: Because that wasn’t the protocol for a woman to be doing that. 69 Q: Okay, it’s okay if you were doing it, but not so much if Joyce is doing it? A: Yes. Q: And why is it okay if you’re doing it? A: Well, it’s not okay. Palmer noted that he was unable to deliver the bag to Matt on Friday, but returned to the shop alone about noon the next day, Saturday, May 30. After removing the bag from the freezer, which Mitchell had left unlocked for him, Palmer looked more closely at the contents, observing now the meat, paints, and an additional item he variously described as a rolled up “green bag,” “rag,” or “cloth.” Palmer said he “squeezed” the item, but did not remove or closely examine it to ascertain if it concealed other contraband. Palmer, again bypassing the metal detector, delivered the bag containing the meat and other items to Matt’s cell. Palmer said he was not concerned about the frozen meat and did not see a need to have it scanned because “I had assumed that it was all hamburger.” In retrospect, however, Palmer acknowledged it “was odd” that the meat’s wrapping lacked a price bar code or store label. According to Palmer, while handing the bag through Matt’s cell door bars, he told Matt, “Here, I don’t want nothing to do with this. There’s paint in there, whatever, just get rid of it, get rid of the stuff.” Asked by the Inspector General why he so advised Matt, Palmer testified, “Because I knew that we were in a gray area with [Mitchell] giving him that meat.” According to Sweat, he extracted the hacksaw blades after thawing the meat in cold water in his cell. Not only did Palmer deliver the tool-laden meat, but, accepting Matt’s offer, he testified that he also “may have eaten” the goulash Sweat prepared from the meat. Having obtained additional hacksaw blades, the next challenge Sweat confronted was determining how far along the steam pipe to cut the exit hole. Sweat said he solved this problem using a mop handle he found in the tunnels. As described by Sweat, he inserted the handle into a very narrow space that ran through the wall around a smaller pipe, noting that the handle extended to within approximately two feet of the outer side of the wall. “So I figured 10 to 12 feet down I should be able to cut my way out” Sweat stated. “I’d be far enough away that I wouldn’t be inside the wall, I’d be close enough where I wouldn’t come out on one of the support pipes that actually hold the steam pipes up.” 70 For the next two weeks or more, from about mid-May to June 4, Sweat toiled nightly cutting an exit hole in the steam pipe. As the pipe sloped slightly downward for drainage purposes, Sweat said, he always entered feet first because “I didn’t want to be upside down.” He then slithered along to the pre-determined exit point. Lying on his back or right side in this tight space, he reached with his left hand to the inside of the pipe and began cutting. “I’m righthanded,” he explained. “I did the whole damn thing left-handed . . . But after like the first day or two, you know, my muscles got used to doing it.” Sweat said it took him almost three days just to penetrate the pipe wall. For illumination inside the pipe, Sweat affixed the LED lights to the pipe’s interior wall with magnets. He used a blanket as a pillow and elbow pads fashioned from socks for comfort. To protect himself from the fiberglass that had come loose while cutting into the pipe, he moistened the inner surface of the pipe with water from a small plastic spray bottle. According to Sweat, the filings produced by his sawing stained his tee-shirt turned rust-colored. Sweat recalled that even with the steam generation idled for the season, the interior of the pipe “was extraordinarily hot . . . I come out of there and I was drenched.” To cool the air inside the pipe, Sweat devised an ingenious ventilation system. On May 7, he purchased a second fan in the prison commissary, which he plugged into the jury-rigged extension cord. Sweat cut and taped together several plastic garbage bags, forming a tube which he fastened to the fan with rubber bands. Once completed, he set up the apparatus just inside the entry hole. Working in the cooler air, he said he could remain in the pipe for three hours at a time, stopping only to “eat a candy bar, drink a little water.” Sweat kept a gallon jug nearby that he refilled as necessary with water from a tap beneath C-Block. Cooling apparatus assembled by Sweat, left, and Sweat’s rust-stained tee-shirt (State Police photographs) 71 Despite the difficulty of working in the confined space, Sweat said, cutting out took no longer than cutting in because the exit hole was only 17 inches by 16 inches, slightly smaller than the entry hole. In addition, according to Sweat, he discovered that cutting rounded corners was quicker than right-angled corners. Sweat said that in the early morning hours of Friday, June 5, he completed the final cut. After sliding the cut-out piece between the pipe and layer of insulation, “I had to kind of kick my way out with my knees” through a portion of the sheathing. It turned out his calculations were perfect – the exit hole was past the exterior of the wall but just short of an obstructing vertical support. As with the holes in the rear walls of Sweat’s and Matt’s cells, doubts were raised after the escape about the possibility of cutting holes in the steam pipe with only a hacksaw blade. Using the same type of blade, the Inspector General conducted a test and was able to cut a threeinch-long hole in a pipe of the same material and thickness in two hours. Hole in steam pipe and protective sheathing outside prison wall (OGS photograph) Sweat Breaches the Prison’s Main Wall and Conducts Test Run of Escape Now outside the prison wall, Sweat climbed from the steam pipe and, still underground, proceeded several hundred yards through the steam pipe tunnel, stopping just short of the entrance to the steam generating plant. A steel gate at this entrance was open. However, observing lights on in the plant and assuming workers were on duty, he backtracked in the tunnel a short distance to an unsecured manhole cover in the plant yard. “I pushed that right out of the 72 way and popped my head out and looked around,” Sweat recalled, but decided it wasn’t a safe place to exit the tunnel due to the risk of being seen by plant employees. Open gate in tunnel at entrance to generating plant and manhole cover just outside plant. (State Police photographs) Sweat then backtracked more than two hundred yards farther in the tunnel to the next manhole cover, which he found secured by a chain. With only a small piece of hacksaw blade remaining, Sweat cut the chain. He then pushed up the manhole cover just enough to see “the old school building” that he recognized from his observations from the Industry Building. “So I kind of knew where I was,” Sweat said. This spot, in the intersection of Barker Street and Bouck Street, was “perfect,” he recalled. “The wall towers couldn’t see.” Moreover, “It would be an easier place for [Mitchell] to see us to pick us up.” Sweat’s conclusion that the manhole cover could not be observed from the prison’s two nearest towers was correct, but of no importance. Neither tower had been manned on the 11 p.m.-7 a.m. shift for almost two decades. While Tower 2, closest to the manhole, was manned on the 7 a.m.-3 p.m. and 3 p.m.-11 p.m. shifts, trees obscured a view of the manhole cover. 73 From Tower 1, the next nearest tower, unmanned on all shifts since 1994, the line of sight to the manhole cover was blocked by buildings and trees. Daytime view from Tower 2: Trees at center block sight of escape manhole cover (Inspector General photograph) As Sweat recalled, “I actually had my head out into freedom” and could have escaped on his own at that moment. But he decided not to leave without Matt “because we had a deal . . . I wanted to stick to my word.” There was also a practical consideration. In his eagerness to keep exploring, Sweat had stayed out of his cell longer than usual. It was almost 4 a.m., and if he had fled then, he would have been gone only a short time before his absence would be noted at the 5:30 count. As it was, he had to make his way back to his cell, wash himself, change clothes, and replace the plate in his cell wall before the count was made. First, however, using parts of a nail clipper, he reattached the manhole cover chain so it would appear intact if seen by a worker. Then, “I ran back as fast as I could.” To celebrate the completion of the escape route, Sweat said, he and Matt had made a plan to share a cigarette when he returned to his cell. As Sweat recounted: “I don’t really smoke, but he bought me a pack of Marlboros, so before I got him up, I lit the cigarette and knocked on his wall and stuck a mirror over so he seen me, seen the cigarette. He goes ‘Are you serious, are you kidding me, you made it through?’ And he thought that, you know, I just made it through the pipe. I 74 said, ‘No, dude, I made it out, twice, and I came back.’ [H]e got all excited . . . I cleaned up and put everything away and went to sleep, I was pretty tired.” With the escape route readied, Sweat and Matt decided they would break out that night right after the final count. Before leaving for his job in Tailor Shop 8, Sweat wrote a last note to Mitchell telling her “tonight’s the night” and reminding her to meet them at midnight and park her vehicle near the manhole cover. Sweat described his final instructions to Mitchell: “I told her you can leave the car running, shut your headlights and stuff off, and you’ll get out of the car, act like you’re talking on the phone, because everybody knows you’re not allowed to drive and talk on the phone, so people who live there, if they look outside and they see you talking on the phone, they’ll say, ‘OK, somebody just pulled over to talk on their phone.’ It’ll be no big deal.” Two Incidents Imperil Escape Plan In the days immediately prior to the escape, two incidents potentially threatened Matt’s and Sweat’s plan. The first occurred on Sunday, May 31, when a fight involving approximately 30 inmates erupted in the prison’s main recreation yard. After the disturbance was quelled, Clinton Superintendent Steven Racette requested authorization from DOCCS central office to impose a lockdown of the entire prison and a search of all cells and other areas. Such a search might have discovered the holes in Sweat’s and Matt’s cells and the breaches in the walls and steam pipe below. DOCCS Deputy Commissioner for Correctional Facilities Joseph Bellnier denied Racette’s request, and no prison-wide lockdown or search took place. Interestingly, Sweat stated he was not concerned that a search would have detected the hole in his cell wall, as “I did a pretty good job of covering it up.” He was less confident about Matt’s work, stating, “They probably would have seen his. He’s kind of a dumb-ass.” Nonetheless, anticipating a search, Sweat said he and Matt disposed of the pepper they had accumulated and intended to use to interfere with tracking dogs they assumed would be part of a manhunt for them after the escape. On Friday, June 5, just hours before the escape, a second incident occurred, this time involving Mitchell and Matt in Tailor Shop 1. The day before, the correction officer replacing Trombley had begun his permanent assignment in the shop. This officer had previously worked as a relief officer in the shop, and Mitchell resented his stricter adherence to regulations. “He glares down at the inmates,” Mitchell said of the officer. Indeed, when Mitchell learned that the officer was to be assigned full-time to the shop, she created a scene in front of other employees 75 by slamming to the floor the clipboard holding the announcement. According to Palmer, Mitchell was worried that the officer posed a threat specifically to Matt, telling Palmer, “He’s going to come here . . . and he’s going to lock up Matt.” As it happened, the officer came close to taking action against Matt on the day of the escape. As noted, that morning Mitchell received word from Matt and Sweat that the breakout would occur that night. The information appears to have unsettled her. “The rest of the day,” Sweat said Matt told him, “she was acting funny . . . she was acting like she was sick, like she was holding her stomach the whole time.” Even so, Mitchell was determined that nothing would interfere with the plan, and her usual overly familiar interaction with Matt continued. Throughout the day, the officer said, Mitchell was “sitting right at inmate Matt’s machine. She was just sitting there chit-chatting. It’s all personal conversation and stuff. I don’t know what she’s saying, but you don’t sit at a machine with an inmate all day long . . . that’s what you have a desk for. You’re there to do a job. . . .” By afternoon, the officer said, he “had enough of it.” Moreover, after observing Matt and other inmates idle at their machines, the officer told them to get back to work. At that point, Mitchell intervened, yelling across the room at the officer, “Leave my fucking inmates alone. If they don’t have any fucking work, they can’t do no work now, can they?” The officer said he responded, “Ma’am, I am security . . . we can’t be having this in the shop.” Seeking an ally in her effort to force the officer to back down, Mitchell called Scott Scholl, the superintendent of industry, asking that a sergeant be summoned. Instead, Scholl sent Bradley Streeter, Mitchell’s direct supervisor. Upon his arrival in the shop, Streeter reprimanded Mitchell, telling her, “[the officer is] security . . . deal with it.” Mitchell, however, remained defiant, recalling to investigators: “My supervisor comes in and says, ‘You can’t yell at your officer.’ I said, ‘Fuck I can’t.’” Unfortunately, despite the officer having quickly identified Mitchell’s improper interaction with Matt, the imminence of the escape precluded effective intervention. Even if the officer had issued Matt a misbehavior report that Friday afternoon, Matt most likely would only have been keeplocked in his cell pending a later hearing. In the meantime, the escape could have proceeded. It is probable, however, that if the officer had begun his assignment in Tailor Shop 1 just a few weeks, or even days, earlier, he would have taken action against Mitchell and Matt, thereby foiling the escape. 76 Mitchell recalled a final gesture Matt made to her as he was leaving the shop at the end of the workday on Friday. Instead of the usual “see you Monday,” Matt offered his raised fist as he headed back to his cell. Sweat’s and Matt’s Final Preparations Sweat stated that he and Matt had informed no one other than Mitchell of their escape plan. However, he said he gave a “heads up” to another inmate who had confided in Sweat his own intent to attempt to escape that same weekend. According to Sweat: “I said, ‘Listen, don’t plan on doing anything this weekend.’ He said, ‘Why?’ I said, ‘Well, there’s some stuff going on and the whole jail’s going to be locked down’ . . . He says, ‘What are you talking about?’ I said, ‘Well, there’s going to be some changes.’” In addition, the inmate in the cell on the other side of Matt in the Honor Block stated that on the morning of June 5, Matt gave him his color television set, a much-prized item at Clinton. The inmate said Matt had promised him the television two weeks earlier, but told him to keep quiet about it. Back in their cells from the tailor shops late Friday afternoon, Sweat and Matt discussed the likelihood of Mitchell showing up at the midnight rendezvous. When Sweat expressed doubt about Mitchell’s reliability, Matt told him not to worry. As Sweat recounted: “[Matt] told her, he said, ‘Listen, you have to be there at twelve.’ She’s like, ‘I’ll be there, I’ll be there’ . . . And he told her, ‘If you’re not there, we’re dead, they’re going to kill us.’ He says, ‘You understand if you don’t show up, they’re going to kill us, we’re dead.’ ‘No, no, I’m going to be there. I’m going to be there.’” Sweat and Matt packed for the escape, filling, according to Sweat, a soft fabric guitar case and backpack. In these they stowed various supplies, including, Sweat said, “clean teeshirts, underwear, socks, sweater.” Sweat said he took with him a new pair of boots he had obtained from another inmate in exchange for a drawing. Although Matt had also recently purchased new boots, by mail-order, he left them behind. According to Sweat, “He had bought new boots and the dumbass wore his old ones.” In addition, Sweat said, they took “like 20 packs of peanuts . . . 40 granola bars . . . probably 12 sticks of pepperoni.” Asked by an investigator how long he had been hoarding food, Sweat replied that he purchased it all at the commissary the day before the escape. In fact, commissary records are consistent with Sweat’s statement. The 77 two also prepared a final meal of chicken and salad, which they shared with the same inmate to whom Matt had given his television. According to the inmate, while passing by Matt’s and Sweat’s cells at about 9:45 p.m. on his return from recreation he was handed bowls of food and told by Sweat, “Enjoy it. I’ll get the bowl back in the morning. Don’t worry about it.” According to Sweat, he and Matt chose Friday night to leave because they wanted the escape to occur on the work shift of Correction Officer Ronald Blair. In fact, Sweat had made notations on the calendar in his cell tracking Blair’s work schedule. Sweat said he harbored a particular dislike for Blair because he considered him unnecessarily disruptive in conducting the 11 p.m. count, when he “went there with a flashlight and banged on [inmates’] feet.” Sweat claimed that because Blair failed to conduct required hourly checks throughout the night, he would face disciplinary charges after the escape. Sweat’s plan had the consequences he intended: both Blair and Thomas Renadette, the second officer working the night shift on the Honor Block, were suspended in the aftermath of the escape. Notes left by Matt in his cell at the time of the escape. (State Police photographs) As was his practice, Blair conducted the 11 p.m. count and determined all inmates were present. After the count, Sweat and Matt completed their preparations by placing dummies in their beds. Matt left two handwritten notes in his cell. One, on a note pad left on a table, stated, “You left me no choice but to grow old & die in here. I had to do something.” A second note, 78 written on a wall calendar illustrated with reproductions of his own artwork, read, “Time to Go Kid!” with the date “6-5-15.” The Escape, Then an Encounter on the Street Sweat said he and Matt began the escape as early as possible the night of June 5, climbing through the holes in their cells just minutes after the final count at about 11 p.m. They quickly descended to the prison’s subterranean level and moved along their prepared route, past two notes Sweat had left the previous night for discovery by their pursuers. Notes left by Sweat on steam pipe, above left, and under B-Block . (Governor’s Office and State Police photographs) Both notes, which Sweat said were written by Matt, on printed images of extraterrestrials, stated, “Are You Trying Me Punk?” Sweat said the message was part of a running joke with Matt that started when Sweat used this expression in the tailor shop and Matt found it humorous. Next to the entry hole on the steam pipe, Sweat affixed a third note – a smiley face on which he had written, “Have a Nice Day.” Sweat said another inmate had given him the note several 79 weeks earlier, but stated that its crude caricature of an Asian face had no particular significance. All three notes were held in place by magnets taken from the tailor shops. On a narrow ledge on the interior side of the prison’s main wall just to the right of the steam pipe, Sweat left a tote-like bag he had sewn from prison-green fabric in the tailor shop which he used to hold his escape tools after each night’s work. The bag still contained a number of tools, no longer needed. Under the bag he inadvertently left behind a plastic pouch containing the New York State map he had taped together from copies of atlas pages. The map, he said, “might have been [useful]” in their flight, showing him and Matt the “best way to take.” Cloth bag made by Sweat to hold escape tools and left in tunnel. (State Police photograph) Sweat said he went through the steam pipe first, followed by Matt who entered head-first with his arms outstretched. Matt, who Sweat said was “afraid of enclosed spaces,” was unable to navigate through the pipe on his own. Therefore, Sweat said, he reached a bedsheet to Matt and pulled him along. As Matt squeezed through the exit hole, Sweat said, “His pants came halfway down and I said, ‘Oh, Matt, I didn’t know you cared.’” Sweat said it was about 11:50 p.m., a little earlier than they had expected, when they reached the manhole. Not wanting to emerge before the scheduled midnight rendezvous, Sweat said, “we just hung out for 10 minutes [to] catch our breath,” then climbed out onto the roadway a block south of the prison wall. Describing later to investigators what he had accomplished, Sweat testified, “Shawshank ain’t got shit on me.” 80 Despite wearing prison-issued pants, Sweat hoped their other attire and the guitar case he was carrying would deflect attention from anyone they might encounter on the street. As Sweat reasoned, “If somebody sees a guitar case, they’re not thinking you escaped . . . they’re going to think you came back from playing in a band or . . . hanging out with your friends. . . .” Manhole from which Matt and Sweat emerged with prison in background hours after escape. (State Police photograph) The disguises received a quick test. Almost immediately after exiting the manhole, an approaching car caused Matt to panic and run into the backyard of a nearby home. Worried that Matt’s actions would betray them as escapees, Sweat yelled to him, “What the fuck are you doing, man? Where are you going?” At that point, Sweat recalled, the car turned into the driveway of the same home, and the driver, who resided there, got out and yelled, “Hey, what are you fucking scumbags doing in my yard?” Sweat replied, “Oh, man, I’m sorry. I apologize. We were just cutting through. We were on the wrong street.” Sweat’s explanation and appearance satisfied the individual, as no further words were exchanged. In fact, when this individual, the stepson of a Clinton electronics maintenance employee, described the incident to State Police after learning of the escape, he recalled that one of the men he confronted “looked like he had a guitar case.” Sweat said a jittery Matt continued to overreact, recalling, “This fucking idiot half the time kept running in people’s yards when he would see a car. I said, ‘Dude, nobody knows you’re out. Just fucking walk like a normal person.’” 81 As Sweat had feared, Mitchell failed to appear at the rendezvous point. Sweat said he and Matt walked around the neighborhood until about 12:20 a.m. Then, realizing that Mitchell had backed out, they fled the area on foot. Mitchell Goes to the Hospital with a “Panic Attack” After completing work at Clinton at 3:30 p.m. on Friday, Mitchell and her husband Lyle Mitchell drove together toward their home, stopping for dinner at a restaurant in Malone. Arriving home later that evening, Mitchell stated, she suffered what she described as a “panic attack.” Waking at about 9 p.m. after a short nap, she said, her symptoms persisted, and, at her husband’s urging, they drove to the Alice Hyde Medical Center emergency room in Malone. Shortly after 2 a.m. Saturday, Mitchell was admitted to the hospital for observation. Soon thereafter, Lyle Mitchell left the hospital and drove home so he could walk their dog and get some sleep. Significantly, Mitchell allowed her husband to return home, despite knowing that Sweat and Matt were likely on the loose and her belief that they planned to murder Lyle Mitchell in the house. Lyle Mitchell returned to the hospital at about 8 a.m. Mitchell stated that at about 11:30 a.m., while preparing to leave the hospital, she turned on her cell phone and learned that the State Police had been trying to contact her. Sweat’s and Matt’s Empty Cells Discovered Ronald Blair and Thomas Renadette, the officers working on the Honor Block at the time of the escape, were responsible for conducting hourly rounds to ensure that inmates were in their cells. On the night of June 5-6, Blair and Renadette filed count slips reporting they had conducted rounds at 11 p.m., 12 a.m., 1 a.m., 2 a.m., 3 a.m., 4 a.m., and 5 a.m., and found nothing amiss. Not until 5:17 a.m., while conducting the 5:30 a.m. standing count, when inmates are required to present themselves by sitting up in bed or standing, did Blair notice Sweat’s and Matt’s absence. Blair described the moment he made the discovery: “I came up the back steps . . . two cells, they didn’t have their lights on, the gallery lights were on . . . [I went to] the 23 cell . . . the light wasn’t on, they weren’t up, I yell to him, no movement. I think I reached in, grabbed the bed, shook it, no movement. I grabbed the sheet and I almost threw up, then saw the dummy. I started off the company . . . I stopped at 22 cell, I did the same thing, 82 saw the dummy, and then . . . off on a dead run. After that, [I was] falling down the stairs.” Blair reported his discovery to Renadette, who was conducting the standing count of other companies in the Honor Block, and they made a quick search of the remainder of 6 Company, finding no trace of Sweat and Matt. Blair then phoned the watch commander, who immediately dispatched two sergeants and other security staff to the Honor Block. Surprisingly, this was not Blair’s first encounter with an inmate placing a dummy in his cell. While conducting rounds at Clinton in 2001, he had reported all inmates present in their cells. However, after finishing work and going home, he was called back to the facility and confronted with the discovery of a dummy in one of the cells he claimed to have checked. Fortunately, the missing inmate had not escaped, but was found in another inmate’s cell with that inmate. As a result of this incident, Blair stated, he has since made sure he is the officer that conducts the first round of the night at 11 p.m., making certain that he has observed all inmates. Notification that Sweat and Matt were missing from their cells was relayed to Clinton’s First Deputy Superintendent Donald Quinn, who arrived at the prison within minutes from his residence nearby. After a briefing by the watch commander, Quinn hurried to the Honor Block, observed the holes in the cells, and ordered the area secured as a crime scene. Thinking that Sweat and Matt might have climbed to the roof of the Honor Block, Quinn checked there but found nothing. Accompanied by a sergeant, he then began a search of the tunnels and soon came upon the hole between B-Block and C-Block, the notes left by Sweat, and other evidence of the escape. While below, he received a radio call from security staff reporting discovery of the cut into the steam pipe just inside the main wall. Quinn raced to the front gate, obtained a firearm from the prison armory, and, accompanied by a State Police officer and police dog, proceeded to the steam plant. From inside the plant, Quinn and the officer climbed a ladder and entered the steam pipe tunnel leading to the prison. According to Quinn, the dog would not follow. Quinn and the officer reached the escape manhole and noticed the severed chain. While the officer remained at that spot, Quinn continued alone through the tunnel until he came to the exit hole in the steam pipe. At that moment, Quinn realized that Sweat and Matt were on the loose outside the prison. Concurrent with Quinn’s arrival at the prison, security staff initiated DOCCS’s escape response. This included notification to DOCCS central office and police agencies, establishment 83 of roadblocks, and other measures. A siren atop the power plant, installed years earlier to alert village residents in the event of an escape, was not sounded. Clinton Superintendent Steven Racette testified that because so many years had passed without an escape, it was believed that if the alarm was sounded now, no one hearing it would know what it signified. Matt and Sweat remained fugitives for approximately three weeks until they were tracked down some 45 miles northwest of the prison. A U.S. Customs and Border Protection officer fatally shot Matt, armed with a shotgun he had taken from a hunting cabin during his flight, in a wooded area in the Town of Malone on June 26. Mitchell said Matt had told her that if he managed to escape, he would “go down shooting” rather than return to prison. A State Police sergeant shot and apprehended Sweat in the Town of Constable on June 28 after Sweat, fleeing across an open field, ignored the officer’s orders to halt. Mitchell, Palmer, and Sweat Are Charged with Criminal Acts Within hours of the escape, State Police investigators questioned Mitchell, whose involvement in the escape was almost immediately suspected. The correction officer just assigned to Tailor Shop 1 learned of the escape when he arrived at Clinton just before 7 a.m. on June 6 to work overtime. With Mitchell’s tirade of the previous day fresh in his mind, the officer reported to a correction captain his concerns about Mitchell’s relationship with Matt. An investigator of DOCCS’s Office of Special Investigations who had investigated the allegation of a relationship between Mitchell and Sweat, reported to the prison on the morning of June 6 after hearing of the escape. Upon seeing photographs identifying Matt and Sweat as the missing inmates, he alerted a correction lieutenant to Mitchell’s possible role in the escape. Both the officer’s and the investigator’s suspicions were quickly reported to the State Police. Confronted by the State Police around 1:30 p.m. on June 6, Mitchell initially played coy. Asked by the State Police during a 90-minute interview if she knew how Matt and Sweat had escaped, Mitchell replied, “I have no idea.” Feigning surprise, she added: “How the hell did they get out of Clinton Correctional . . . Because I just – I’ve never heard of anybody getting out of there. That’s why I just – I mean, how they – even Lyle said that, you know, ‘How did they escape out of there?’ I said, ‘I don’t know.’” The following day, June 7, the State Police again questioned Mitchell, and, after continuing to deny any involvement during more than an hour of further questioning, she made a partial 84 admission, confessing to smuggling escape tools and taking other actions to assist in the escape. During the next 3½ months, over the course of eight interviews with the State Police and two interviews with the Inspector General totaling nearly 50 hours, Mitchell’s account of her involvement in the escape slowly evolved. When pressed for answers, Mitchell reluctantly revealed additional details not previously disclosed. On a significant point, Mitchell over a period of more than three months repeatedly denied smuggling six hacksaw blades to Matt and Sweat in February 2015, and only admitted to this act when the Inspector General confronted her with records of her purchase of the blades. On June 12, the State Police arrested Mitchell on a felony charge of Promoting Prison Contraband and misdemeanor Criminal Facilitation. Mitchell was suspended and subsequently resigned from DOCCS employment. Following prosecution by Clinton County District Attorney Andrew Wylie, Mitchell pled guilty in Clinton County Court to both charges on July 28, 2015. On September 28, 2015, she was sentenced to a term of 2⅓ to 7 years in state prison. On November 6, 2015, Mitchell was ordered to make restitution of $79,841 and a 10 percent surcharge to the state for costs relating to the repair of the walls in Matt’s and Sweat’s cells and pipes and walls in the tunnels. Palmer was arrested by the State Police on June 24. He was charged with Promoting Prison Contraband, a felony, for providing a screwdriver and pliers to Sweat on four occasions; Tampering with Physical Evidence, a felony, for burying paintings he received from Matt and Sweat; Tampering with Physical Evidence for destroying paintings he received from both inmates; and Official Misconduct, a misdemeanor, for accepting paintings from Matt and Sweat in return for introducing contraband into the prison. On October 7, an additional felony charge of Promoting Prison Contraband was filed against Palmer for introducing frozen hamburger meat into the prison and providing it to Matt. Palmer was suspended by DOCCS. On February 29, 2015, in full satisfaction of all charges, Palmer pled guilty to felony and misdemeanor counts of Promoting Prison Contraband and one count of Official Misconduct, a misdemeanor, and was sentenced to six months in county jail and fined $5,000. As part of his plea, Palmer resigned from state service effective that date and waived his right to appeal. After his capture and treatment for his wounds at Albany Medical Center, DOCCS transferred Sweat to Five Points Correctional Facility in Romulus. DOCCS initiated disciplinary charges against Sweat for the escape, and, after being found guilty in a disciplinary hearing, he 85 was sentenced to six years of confinement in special housing, where he is confined for 23 hours a day, and six years of loss of package, commissary, and telephone privileges, beginning July 15, 2015. Sweat is appealing the terms of his special housing confinement. On August 20, Sweat was arraigned in Clinton County Court on felony charges of Escape and Promoting Prison Contraband. On November 13, 2015, he pled guilty to all counts. On February 3, 2016, Sweat was sentenced to 3 ½ to 7 years on each of two counts of First Degree Escape and one count of First Degree Promoting Prison Contraband and ordered to pay $79,841 in restitution. Following the escape, DOCCS took action against Clinton executive management officials and other employees. Superintendent Steven Racette, First Deputy Superintendent Donald Quinn, Deputy Superintendent for Security Stephen Brown, and numerous uniformed staff were suspended. Racette later retired and Brown later resigned. Additionally, Assistant Commissioner Patricia LeConey retired during the pendency of the Inspector General’s investigation. The Inspector General’s investigation identified a number of DOCCS employees who committed criminal acts and violated DOCCS directives and policies. DOCCS has taken and will continue to pursue affirmative steps to appropriately discipline employees implicated in the Inspector General’s investigation. Many of these employees have resigned or have been terminated. Additionally, DOCCS has been cooperating with the American Correctional Association, which is assessing New York State’s prison operations to ensure compliance with national standards. The Inspector General is providing the results of this investigation to the Association to assist with its endeavors. The Inspector General has referred these matters to the Clinton County District Attorney’s Office, the New York State Joint Commission on Public Ethics, and DOCCS. 86 ANALYSIS OF FACTORS IN THE ESCAPE OF SWEAT AND MATT A combination of factors made possible the escape of Richard Matt and David Sweat. Sweat’s ingenuity and persistence, Matt’s ability to manipulate Joyce Mitchell and Eugene Palmer, Mitchell’s willingness to commit criminal acts, and Palmer’s negligence in delivering escape tools, were the obvious causes, as the report describes above. These factors, however, do not fully account for the escape. The events of June 5, 2015, could not have occurred except for failures in fundamental security operations at Clinton, as well as inadequate oversight of these operations by Clinton management and DOCCS. Critical lapses identified by the Inspector General’s investigation include the failure to search containers carried by employees entering and exiting the prison’s front gate; counts of inmates during the night that were improperly conducted or not done at all; cursory cell searches that omitted examination of cell wall integrity; tunnel inspections that did not occur as frequently as intended; and breakdowns in security and civilian employee supervision in the prison’s tailor shop where Mitchell was employed and improperly interacted with Sweat and Matt. Joseph Bellnier, DOCCS deputy commissioner for correctional facilities since 2011, testified that these multiple failures amounted to a “culture of carelessness” regarding security at Clinton. Indeed, the Inspector General’s investigation found overwhelming evidence that superior officers and civilian managers were, or should have been, aware of these failures. Interestingly, one inmate who observed these failures and understood their significance, testified: “There’s nothing wrong with the system. It’s just that people got to follow the rules that are in place . . . But if you can have people who are supposed to be implementing the rules and policies picking and choosing who they want to implement the rules and policies on, therein lies the imbalance. You know, that’s what the problem was.” The Inspector General also found that a number of deficiencies existed in DOCCS central office operations. Various audits and inspections of Clinton’s security conducted by DOCCS, as well as by Clinton management, were so superficial as to be virtually without value. DOCCS failed to take sufficient action to ensure that security lapses that had contributed to an earlier escape at Elmira Correctional Facility did not occur at other facilities. An investigation by the DOCCS Office of Special Investigations inquired into the relationship between Mitchell and Sweat in February 2015, but was deficient as it failed to interview all relevant witnesses. 87 These specific shortcomings, among others identified by the Inspector General’s investigation, are described in detail and analyzed below. Failure to Properly Search Employee Bags at the Front Gate Preventing contraband from entering a prison is of paramount importance in ensuring security and safety. To control contraband, DOCCS and Clinton have promulgated policies governing searches of individuals, containers, and vehicles at the prison’s entrances. The Inspector General’s investigation found, however, that inadequate enforcement of the policy has made the Clinton front gate porous and a search of employees’ bags a rarity and not the norm. Indeed, this negligence enabled Joyce Mitchell to smuggle the very tools of Matt’s and Sweat’s escape, including hacksaw blades and chisels, into the prison with little fear of detection. It also facilitated Correction Officer Eugene Palmer’s frequent ferrying of contraband painting supplies to Matt and Sweat and removal of more than a dozen of Matt’s paintings intended for himself and others. Front Gate Search Requirements DOCCS policy for security in gate areas requires the “proper screening and/or searching” of all individuals and vehicles entering a prison “to protect the well-being of both inmates and staff [and] assure the safety and security of the facility.” Similarly, Clinton policy for the front gate mandates “stringent security measures . . . to prevent the introduction of contraband into the facility.” Under DOCCS and Clinton policy, employees entering the prison must present proper identification. Policy further states that employees entering and exiting the prison may be subject to search, including by metal detector or hand scanner. In addition, policy requires that all containers and bags carried by employees into and out of maximum- and medium-security prisons be searched. Underscoring the requirement that all containers and bags will be searched, on September 23, 2014, Joseph Bellnier, the DOCCS deputy commissioner for correctional facilities, issued a memorandum to all superintendents. The memorandum reads: “Uniform personnel are permitted to carry one (1) container to their post within population large enough to hold their food AND approved items necessary to protect them from outside elements. Such container may be a backpack, gym bag, or duffel bag (no camouflage color) . . . All containers carried by staff into a 88 correctional facility will be searched at the facility entrance upon entering and leaving the facility.” [emphasis supplied.] Responding to Bellnier’s communication, Clinton Captain Patrick Devlin addressed a memorandum to Clinton Superintendent Steven Racette reporting the results of a “front gate survey.” In his memorandum, Devlin stated that his survey had found that “all bags and/or containers of facility staff [are] frisked.” Further, Devlin stated, “I do not recall ever conducting an employee frisk at the [front gate].” In light of the findings of the Inspector General, Devlin’s claim that all employees’ bags and containers are searched at the front gate is clearly wrong. In addition, Devlin’s statement that employees at the front gate had historically not been frisked was accurate and should have should have been addressed by Racette. DOCCS policy generally defines contraband to include items that are illegal for the public to possess and that can be used as weapons. The definition further includes items “[w]hich could be utilized to assist with or effect an escape or undermine the safety and security systems and/or practices” and those “introduced into the correctional facility with the intent to transfer . . . to an inmate without permission of the Superintendent or designee. . . .” Cell phones and weapons must be surrendered at the front gate, except in special circumstances. The Front Gate at Clinton Clinton’s front gate, which includes a pedestrian entrance and a vehicle “sally port,” is located on the southwest corner of the facility. All facility employees and visitors must enter and exit the facility through the front gate, which is staffed by a lobby officer and a console officer. Entry to the prison is controlled by the console officer, who is stationed within a glass booth adjacent to a reception area and operates three electronically-controlled security doors/gates, only one of which may be open at any one time. The first door provides access to the reception area, where the lobby officer greets and processes all staff and visitors entering the facility. After processing in the reception area, staff must pass through a sliding gate into the checkpoint area. The checkpoint area houses a walk-through magnetometer. After clearing the checkpoint area, the console officer opens the third door providing access to the facility grounds. Contractors and delivery drivers, along with their vehicles, enter the facility through the sally port, where the vehicles are inspected, their contents inventoried, and a security escort is assigned to accompany them within the prison. Persons reporting to the facility on professional 89 business are required to present identification, sign the visitor log, and obtain a gate pass. Those visiting the facility on a regular basis, like clergy, mental health professionals and volunteers, may be given long-term gate clearance. Visitors, except for professional visitors, are required to pass through a magnetometer. Evidence of Non-Compliance with Search Policy The Inspector General’s investigation revealed flagrant violations of front gate security requirements. During the investigation, Clinton employees were observed entering and exiting the facility with large bags or other containers on numerous occasions. In most instances, employees walked through the gate without their containers or bags being opened or inspected. On some occasions, officers conducted a cursory inspection that involved only briefly viewing the immediately visible contents of an opened container or bag. Startlingly, this failure to comply with search requirements occurred in front of plainly identified investigators of the Inspector General’s Office who were on-site after the escape. On no occasion did investigators observe a thorough physical search or a magnetometer scan of the bags. Testimony from current and former staff corroborated these observations. This included Joyce Mitchell, who described the ease with which she smuggled in hacksaw blades and other tools used by Sweat and Matt in their escape. When asked about a particular escape tool she provided to the inmates, the following exchange occurred: Q: Okay, and then what? How did you get it into the facility? A: I just carried it in my bag. Q: Through the front gate? A: Yup. Q: Was your bag checked? A: . . . No, it wasn’t. . . . Q: Has it ever been checked? A: Not very often. Q: What does that mean, not very often? Has it ever been checked? 90 A: The only every time you would actually ever see them check your bag, or even ask for your ID, was if there was a sergeant or a lieutenant, or the superintendent, or captain coming through; otherwise, very seldom . . . Q: And in the few times they actually did check your black bag, to what degree did they check your black bag? How did they check it? A: They just have you unzip it, and they look in it. Vicki-Lynn Safford, the quality control supervisor in Clinton’s tailor shops for almost 17 years, testified that her bag was almost never opened for inspection. “Once in maybe six months, someone would look,” she said. She further noted she was never required to walk through the magnetometer and never observed any civilian staff subjected to a pat frisk or magnetometer wand scan. A retired Division of Industries senior industrial training superintendent who worked at Clinton for more than four years, testified she observed occasions when officers failed to open their own bags for search and were not directed to do so by the lobby officer. Similarly, a retired correction officer testified that front gate officers do not search bags because supervisors “just told us to look in the bag and that’s what we did.” According to the officer, “They open the bag and we just glance inside . . . We don’t pull stuff out of the bags . . . We did not reach into the bag.” Additionally, a number of staff interviewed by the Inspector General testified that a single lobby officer is unable to conduct anything more than quick visual inspection of bags. To do more would cause a substantial delay of personnel reporting to work. Further, another correction officer, who works various positions including the front gate, testified that at times only a Console Officer was on duty at the front gate, and no other officer was present and available to inspect bags. Despite the directives mandating searches, a number of officers told the Inspector General they believed they were not permitted to physically search employees’ bags or process the employee or their bags through the magnetometer without proper authorization. A proper search at the front gate would have detected Officer Eugene Palmer carrying a cell phone into Clinton, in violation of DOCCS policy prohibiting cell phones in prisons. Palmer testified that in early 2015, he took a personal cell phone into Clinton. In his testimony, he described how this occurred: Q: And so how did you get it into the facility? Right through the front gate? 91 A: Yes. Q: And were your bags checked on that occasion? A: No. Q: Not even superficially checked? A: No. Photograph taken inside prison on cell phone depicting, left to right, Correction Officers Eugene Palmer, Mary Lamar, Theodore Sweet, and Scott Giguere. According to Palmer, while in the Honor Block, he handed the phone to an inmate whom he asked to take a picture of himself standing with Correction Officers Mary Lamar, Theodore Sweet, and Scott Giguere. Palmer said he retrieved the phone from the inmate immediately after the picture was taken and placed it in his locker in the administration building. Palmer acknowledged that he was aware of policy prohibiting the possession of cell phones and the taking of photographs in prisons, and that he did not request or receive permission to have the phone in Clinton or to take a picture on the date in question. That the three other officers depicted in the photograph were clearly aware of Palmer’s misconduct but took no action, suggests that the presence of an employee’s cell phone in the prison was not uncommon. Night Counts of Inmates DOCCS policy states that the “first responsibility of the Department is custody of persons committed to terms of imprisonment.” An essential part of this responsibility is counting and observing inmates in the prison at specified times. However, the Inspector General’s 92 investigation revealed that officers on the night shift in the Honor Block conducted night counts inadequately, or not at all, over a long period, failing to detect Sweat’s near-nightly absences from his cell as well as Sweat’s and Matt’s escape late on June 5. These failures are startling, given that night-shift officers have virtually no responsibility other than performing counts and rounds with no distraction from inmate activity or movement to programs. In addition, the investigation found that officers throughout the prison completed and certified night count forms before the counts were actually conducted. Clinton management lacks a procedure to verify that night shift counts are occurring, relying on representations made by officers responsible for the counts. Notably, with the exception of the Special Housing Unit, no housing block at Clinton is equipped with cameras that could monitor officer and inmate activities. Inmate Count Requirements DOCCS policy mandates accurate counts of inmates at prescribed times, and at frequent intervals, to verify custody, ensure that inmates are in their authorized places, and ensure that all inmates are alive and well. The policy prescribes various types of counts, including master counts and unscheduled counts. Master counts are to be completed at scheduled times and account for every inmate in the facility. The directive mandates that master counts be conducted four times a day, including one in the morning and one in the evening. Two other master counts are to be conducted at times specified by the superintendent. During these counts, inmates must be locked in their cells and are required to sit, stand or be positioned such that it is readily apparent that he or she is alive and easily identified as the person assigned to the cell. The results of master counts must be reported on a count slip and forwarded to the watch commander’s office for review and recording. Unscheduled counts, known as rounds, are informal counts conducted at frequent intervals, at least hourly. Unscheduled counts, which are typically conducted while inmates are working or at recreation, do not require formal documentation. Night counts are conducted while inmates are usually sleeping. Policy states, “In performing a Night Count, the employee has one paramount responsibility, which is to observe and report the presence of living bodies or the absence of assigned inmates.” Although officers have a secondary responsibility not to unnecessarily disturb a sleeping inmate, they must see “skin and breathing or other movement” for each inmate. Policy notes that escapes have 93 occurred, and that officers “must always bear in mind that inmates, knowing that employees do not wish to disturb sleeping inmates, have skillfully constructed dummies to delay the detection of escapes.” If skin and movement are not observed, alternate means delineated in policy must be used to ensure that a living inmate is present. These means include: lightly shaking the end of the bed; calling the inmate’s name; lightly tugging the blanket or sheet; shining the flashlight beam at the inmate’s head; or lightly tapping the flashlight or baton on the bed, cell bars or door. An employee conducting the count must immediately notify a supervisor if there is no inmate movement or the inmate cannot be roused. Policy also requires officers to record the results of counts. Each employee conducting the count must print and sign the count slip. The watch commander uses the slips to compile a master count, and then totals and signs the master compilation. Grand totals and employee signatures must be in ink. Of significance to this investigation, policy states that “[u]nder no circumstances are count slips to be completed prior to the actual count.” Moreover, at the DOCCS Training Academy, recruits are taught that two of the most common errors made during inmate counts are filling out count slips in advance and counting cells instead of living, breathing inmates. Clinton Inmate Counts: Policy and Practice Clinton policy on inmate counts differs from the DOCCS directive in one important respect. While the directive mandates four master counts per day, Clinton policy requires only two such counts, one at 5:30 a.m. and the second at 10 p.m. In addition, Clinton policy requires counts at 12 a.m., 2 a.m., 4 a.m., and 5:30 p.m. Pursuant to practice, Clinton officers also purportedly conduct rounds at 11 p.m., 1 a.m., 3 a.m., and 5 a.m. While not required to report the rounds, barring a missing inmate, they do so on a count slip. However, the rounds, although documented, are not later entered by the watch commander on the Night Count Sheet. The three tiers of the Honor Block each contain two control rooms – one for each company. During the 11 p.m. to 7 a.m. shift, at least two officers work on the Honor Block. The officers work out of a control room on the first tier and are responsible for conducting and documenting the hourly counts and rounds on all three tiers, and making entries in the unit log. 94 These entries should include the names of the assigned officers, significant events, and the times of counts and rounds. The Honor Block on the Night Shift The Inspector General interviewed all officers currently assigned to the Honor Block on all shifts, as well as all officers, including relief officers, who worked the night shift during the three-month period Sweat was out of his cell and in the tunnels below the prison. All the officers testified that they conducted all hourly counts and rounds. Ronald Blair, who worked on the Honor Block the night of the escape, testified he conducts a count at 11 p.m. when he arrives for his shift, and wakes any sleeping inmates to ensure they are present and alive in their cells. As for subsequent counts and rounds, Blair said, “They don’t want us waking them up . . . If they look . . .alive to you, you move on to the next one.” When asked what he does if he does not see skin or movement, Blair claimed, “If I feel that something is wrong, I wake them up.” Blair purportedly conducted the night rounds at 12 a.m., 2 a.m., and 4 a.m., and signed count slips reporting that all inmates in the Honor Block were present. Blair testified that he was certain he made the rounds on the night of the escape, and that he thought Matt and Sweat were in their cells that night: “That’s been eating me up. I thought they were in their cells. I thought they were alive. Believe me, if I wouldn’t have thought that, I wouldn’t have waited to the 5:30 count, the live count, to call it in…. I honestly thought that they were in their cells.” Investigators asked Blair whether, based on his familiarity with conducting rounds for more than 13 years, he may have been too inattentive in checking for human movement. Blair conceded, “That is possible . . . I’m not going to rule that out.” Blair also revealed to investigators that he previously had failed to notice the absence of an inmate from his cell on three counts during the night shift on August 30, 2000, while working in another housing block at Clinton. On that date, Blair submitted count slips indicating the inmate was present in his cell when in fact he was with another inmate in that inmate’s cell. Blair stated that he subsequently altered his practice when doing rounds on the night shift, including in the Honor Block. According to Blair, when conducting his first round at 11 p.m., he made sure all inmates were awake, even if that required rousing them from sleep. This action 95 exceeds what is required in the DOCCS directive, which states that officers must observe “skin and breathing or other movement,” but doesn’t require them to wake inmates to do so. Correction Officer Thomas Renadette, who worked with Blair on the Honor Block the night of the escape, also testified he conducted all required counts and rounds, and signed the corresponding count slips. He noted, however, that it is difficult to observe “skin and breathing or other movement,” as policy mandates, because inmates often sleep with their heads covered. While both Blair and Renadette stated they never slept during their shift, Blair testified he observed Renadette reclining in his chair or with his feet on the desk in the control room. Blair recalled, “Feet up? Yep. We’d get lazy. You’ll be doing a crossword, whatever, I’ll be reading a book. We get lazy. But we’re still paying attention to what’s going on in the block. . . .” Other officers on the Honor Block night shift also claimed they made required rounds. Correction Officer Melody Moore, who worked the night before the escape as a relief officer, testified that when conducting overnight counts and rounds she assured herself that inmates were in their cells: “I have a flashlight. On my first round, obviously you make sure they are there and are alive.” Moore further stated that she will wake an inmate when she cannot see their head: “Myself personally, if they’re all covered up, head’s covered, I can’t see them moving at all, I am going to wake them up.” In such instances, Moore said, she will “[t]ap on the bar with my flashlight.” According to Moore, on subsequent counts and rounds “throughout the night . . . we make sure that there’s a body, or you presume there’s a body. . . .” On these later counts and rounds, Moore said, “[Y]ou don’t flash the light in their eyes, you just, enough to tell that there is somebody there” without waking the inmates. In addition, Moore said she does not tap on the bars during these later counts and rounds. Significantly, Moore’s actions on all but her first count are inconsistent with directive and policy, which require officers to confirm “skin and breathing or other movement” on all counts, even by tapping on cell bars or other means. Officer Michael Dupuis, who had worked the night shift in the Honor Block three nights a week since approximately October 2014, testified that during counts and rounds he “makes sure that all the cells are locked up . . . shine your [flash]light, making sure there’s somebody in there breathing.” When asked what officers on the overnight shift do between counts, Dupuis stated, “[w]e just hang out in the office, might be sipping on some coffee or something, you know, B.S.’ing.” Dupuis acknowledged that there are nights he wants to nap, and that it can be difficult to stay awake, but stated “we keep it going.” 96 Notably, a number of officers advised the Inspector General they believed they were prohibited from using a flashlight to ensure the presence of living inmates during night counts. In fact, policy specifically allows use of a flashlight, among other means, when an officer cannot observe skin and breathing or other movement. Contrary to the claims of officers, former Honor Block inmates interviewed by the Inspector General testified that officers did not conduct counts and rounds after the 11 p.m. count and before the 5:30 a.m. count. Sweat, as noted, said he was confident enough these rounds were not conducted to exit his cell nearly every night to work on the escape route without fear of discovery. Seven other inmates also testified that officers failed to conduct these counts. One of these inmates testified: “They do their initial count, 9:15 [p.m.], 9:30 [p.m.], and everybody locks in, and they’ll come maybe about 20 minutes after 10 [p.m.], some different officers will come closer to 11 [p.m.], that’s very rare. After that, you don’t see them . . . One of the best things I like about, put the curtain up and just you’re by yourself . . . Dead quiet, by 9:30 [p.m.], it’s the best thing about that whole block, 9:30 [p.m.] it’s dead quiet.” Similarly, another inmate testified that many officers working on the Honor Block did not conduct rounds after the 11 p.m. count. According to yet another inmate, this was the norm, stating that after an officer conducts the 11p.m. count, “you don’t see him ‘til 5:30. I’ve been up a few nights on the weekend. They don’t come back.” A fourth inmate testified, “The CO’s do a round at 11:45 p.m. around the whole block 1-6 companies and don’t walk again until 5:30 a.m. count.” Most significant is the fact that Sweat and Matt were not reported missing until the morning of June 6, more than six hours after they had exited their cells. Moreover, Sweat’s almost nightly absences from mid-March to early June while he toiled in the tunnels were never detected. These facts are compelling evidence that officers regularly failed to conduct required counts. In the time Sweat was out of his cell over a three-month period, a total of more than 400 counts should have been conducted. If only one of the counts was done properly, the escape plan would have been instantly stopped. Night Shift Officers Completed and Submitted Inmate Count Slips Prior to Counts Pursuant to Clinton policy, officers are required to fill out slips documenting their completion of inmate counts at 12 a.m., 2 a.m., 4 a.m., and 5:30 a.m. The slips for these counts 97 bear an attestation that reads, “I certify this count to be correct,” and a signature line. Pursuant to Clinton practice, officers also complete slips for rounds performed at 11 p.m., 1 a.m., 3 a.m., and 5 a.m. Upon completion of their counts and rounds, officers are required to sign an attestation on the slip that reads, “I certify this count to be correct.” In addition, one officer on each block is required to make an entry in the unit log reflecting completion of counts and rounds. According to policy, the completed slips are to be picked up hourly by an officer referred to as the “roundsman,” and taken to the watch commander’s office. There, the watch commander compiles the results of the count slips into a master count sheet. As noted, DOCCS policy explicitly states that “[u]nder no circumstances are count slips to be completed prior to the actual count.” The Inspector General’s investigation revealed, however, correction officers in all blocks at Clinton completed and signed night count slips prior to the counts. Officers also testified that this practice occurs in other DOCCS correctional facilities. Moreover, the investigation found that roundsmen only retrieve count slips once during their shift. Dupuis testified that he conducts counts and rounds at 12 a.m., 1 a.m., 2 a.m., 3 a.m., 4 a.m., and 5:30, but completes and signs all of the count slips when he arrives in the block at the start of his shift at 11 p.m. According to Dupuis, the roundsmen “collect, like I said, the 12, 1, 2, and 3 at . . . quarter to 12 to 12:30, in that time frame.” The remainder of the count slips are then retrieved around 5 a.m. by Correction Officer Dennis Lashway, who also opens the blocks and “unlocks” the prison. Similarly, Blair admitted he completed and signed the count slips prior to the counts. Specifically asked by investigators if he signed the certification on count slips on the morning of the escape before the purported counts had occurred, Blair replied, “Yes.” Blair testified that pre-filling count slips is a longstanding practice at Clinton, stating, “That’s the way it’s always been.” Blair also testified that roundsmen did not pick up count slips throughout the shift, but only at about 12 a.m. Renadette testified that the practice of officers completing count slips and roundsmen collecting them prior to actual counts has existed in all housing blocks at Clinton “as long as I’ve been there . . . for 33 years.” Renadette stated that if the actual count differed from that on the pre-filled slip, officers retroactively corrected the record. According to Renadette, a “new count will be made up and it will be picked up in the morning with the remaining counts.” Renadette 98 continued, “[a]nything that hadn’t been picked up … we will take that one, destroy it because it’s no longer valid, and make a new one. . . .” Renadette acknowledged the serious nature of signing a certification on count slips prior to the count occurring: Q: And when you certify documents . . . what is it that you believe that you’re doing? A: I believe that I’m, you know, falsifying a document. Correction Officer Jason Hebert similarly recognized the misconduct inherent in prefilling count slips. Asked how slips can be completed and collected prior to the counts, Hebert answered, “It’s basically falsifying.” Roundsmen Collect Housing Block Count Slips Prior to Actual Counts Officer Barry Chauvin, a roundsman on the night shift, testified that he begins rounds each night between 11:30 p.m. and 12 a.m., shortly after starting work. In addition to collecting count slips from housing blocks and delivering them to the watch commander’s office, Chauvin said he is responsible for patrolling the prison grounds on foot to ensure all entrances, exits, and gates are secure. Chauvin stated that he collects slips only “one time” before midnight each shift, when he picks up completed slips for the 12 a.m., 1 a.m., 2 a.m., and 3 a.m., counts, before officers have conducted these counts. According to Chauvin, “It’s always been that way, as far as I know,” adding that he never questioned this practice. “I was just doing what I was told to do as directed,” Chauvin stated, noting that he received training at the time he began roundsman duties on May 31, 2015. Chauvin confirmed that this practice has continued since the escape. Chauvin asserted that a single officer does not have enough time during a shift to collect count slips each hour from all the blocks as well as conduct required inspections. Officer Dennis Lashway, who starts his shift at 4:20 a.m., collects the second group of pre-filled count slips. According to Lashway, he unlocks each housing block, retrieves the 4 a.m., 5 a.m., and 5:30 a.m. count slips, and completes his rounds by 5:05 a.m. “The “grass doesn’t grow under my feet,” Lashway stated in reference to the quick completion of his rounds. Lashway testified that although he was aware that the “the 5:30 [master] count hasn’t taken place yet,” he never questioned the practice. “It’s been done in a lot of other jails,” he stated, noting he was just following orders and that counts had always been picked up in this manner. 99 Watch Desk Officer and Watch Commander Complete Night Check Count Sheets Using Prefilled Count Slips The night shift at Clinton is supervised by a watch commander and assistant watch commander, with the help of a count desk officer, all located in the administrative building. The watch commander, a lieutenant, oversees staffing, unusual incident reports, inmate misbehavior reports, and the master count, among other duties. The assistant watch commander, a sergeant, accounts for all staff, prepares charts for the day shift, and processes officer disciplinary actions. The count desk officer, a correction officer, is responsible for receiving count slips from the roundsmen and entering count information on the Night Check Count form. Christopher Gadway, the Count Desk Officer in the Watch Commander’s office, is responsible for setting up the Night Check Count form, which documents the 12 a.m., 2 a.m., and 4 a.m. facility counts. Gadway testified that when he reports for duty at 10 p.m., he reviews the prison master count for that night and pencils in the expected data on the new blank Night Check Count sheet under the 12 a.m. count section of the form. At approximately 12:30 a.m. the roundsman provides Gadway with completed and signed slips for all counts between 12 a.m. and 3 a.m., which have not yet been conducted. Gadway said that other than the 12 a.m. count, he does not routinely pre-fill counts on the Night Check Count Sheet. Gadway then gives all the housing block count slips and the Night Check Count Sheet to the Watch Commander to complete during the night. On the occasions when the Watch Commander leaves the office for an emergency, Gadway said that he completes the Night Check Count sheet for the rest of the shift, to include filling in the 2 a.m. and 4 a.m. counts. The 4 a.m., 5 a.m., and 5:30 a.m. count slips are brought up to the Watch Commander’s office when Lashway, the officer who “opens up the jail” completes his round around 5 a.m. In an attempt to justify the pre-filing of count slip, Gadway stated, “We don’t have enough manpower to go around every hour to pick up the counts.” He further stated that pre-filing count slips has always been the practice. Gadway admitted that this violates the DOCCS directive. Lieutenant Terry Brunet, the overnight shift Watch Commander since 2013, testified that master counts are called in to the Watch Commander’s office. As for the other counts, Brunet admitted that roundsmen turn in pre-filled slips for 12 a.m. through 3 a.m. counts, which have not yet occurred, a practice he said has existed since he began employment at Clinton. Brunet 100 claimed that due to time constraints, roundsmen retrieve and submit count slips prior to actual counts: “They pick it up because he physically doesn’t have the time to go and pick up those counts every hour and still get his duties done that he’s supposed to do. So when I got there, and I don’t know how long prior, but this is the way it was done.” According to Brunet, he enters the counts onto the Night Check Count form for hours of 12 a.m., 2 a.m., and 4 a.m. On a “5:30 AM Opening Master Count Sheet,” Brunet enters the 5:30 a.m. master count results. Brunet said he makes entries on both forms with a pencil so they may be erased if there are changes. He also signs both forms in pencil, which violates policy requiring that both count totals and signatures be in ink. Brunet, who was on duty the night of June 5-6, said he was alerted to the escape by Blair around the time of the 5:30 a.m. master count. However, Brunet, relying on the pre-filled count slips, had already completed the “5:30 AM Opening Master Count Sheet” reporting all 30 inmates in 6 Company of A-Block – the unit that housed Sweat and Matt – present in their cells. Moreover, Brunet also had signed in pencil the line on the form attesting, “I Certify This 5:30 AM Count To Be Correct,” but then erased his signature. When questioned by the Inspector General how he certified a count that included Sweat and Matt as present hours after their escape, Brunet attempted a tortured explanation. Brunet acknowledged he “may have” signed the count before 5:30 a.m. However, he claimed he had “signed by accident” and then “erased it right away” because “the count wasn’t certified.” Asked how he could have “inadvertently” signed the master count, Brunet responded that although “I understand how ridiculous it sounds,” he might have thought he was signing “another piece of paper that was already on top of [the master count].” Given Brunet’s far-fetched account and the fact that count documents were pre-filled as a routine practice, it is almost certain that Brunet completed and signed the master count in advance, and only erased his signature after learning that Sweat and Matt were missing. Clinton Management Claims of Being Unaware of Prefilling Practice The Inspector General determined that the practice of pre-filling count slips on overnight shifts was longstanding and widely known among security staff at Clinton. In addition to Brunet and other officers noted above, Lieutenant Christopher Delutis, a Watch Commander, and 101 Captain Patrick Devlin confirmed they were aware of the practice. However, Clinton executive management officials claimed they had no knowledge of this longstanding activity. Brown, the former deputy superintendent for security, when asked if he would be surprised to learn that officers testified to completing count slips on the overnight shift prior to the actual count occurring, testified, “Yes, it would be a surprise, yes, sir.” He added: “Should [it surprise me], no. Unfortunately, no. We don’t do a frickin’ thing on midnights except for manning a round. I don’t know why you would have to fill out - - your count list [in advance], but could see people doing it, yes.” *** “I should have known, if it was. I would have told them don’t do it.” Similarly, First Deputy Superintendent Donald Quinn testified that he was unaware that night shift corrections officers were pre-filling count slips and that roundsmen collected the prefilled count slips before the counts occurred. When told that this practice was condoned by the watch commander, Quinn responded: “Shame on him, that’s not what to do.” Former Superintendent Steven Racette testified, “I haven’t heard of that.” Cell Searches DOCCS policy states that the possession and use of contraband by inmates “threatens the security of the facility” and “endangers the safety of inmates, employees, visitors, and the community. . . .” As policy further states, cell searches “are essential to the discovery and elimination of contraband.” The Inspector General’s investigation revealed that Clinton practice does not ensure that all cells are regularly searched, and that cell searches, when conducted, are hasty and inadequate. Significantly, a search of Matt’s cell in March failed to detect the large hole he had cut in the cell’s rear wall. Cell Search Policy and Practice Pursuant to policy, different types of cell searches occur, the most common being daily searches of randomly selected cells. Cells are also searched in response to specific problems or threats, or when there is reasonable suspicion that contraband is present in a cell. The Inspector General’s investigation revealed deficiencies in DOCCS policy and Clinton practice regarding random cell searches. The deficiencies begin with a seeming contradiction between the DOCCS Directive 4910 addressing cell searches and a Clinton 102 memorandum on “Random Daily Cell Search.” The directive requires facilities “each day” to conduct searches of “the living quarters of a number of inmates in each housing unit . . . in accordance with a schedule established by the Deputy Superintendent for Security or equivalent.” The schedule should “ensure that each inmate’s cell, cube, or room is randomly searched within a specific timeframe.” A plain reading of the directive indicates that on a daily basis, more than one cell must be searched in a unit. However, the definition of “unit” is unclear when compared to the memorandum, which states, “Only one cell per block/unit needs to be frisked.” This would appear to mean that “block,” a building housing inmates, is synonymous with “unit.” However, in the memorandum’s tabular section, “unit” is equated with company, the 30 or so inmates residing on one side of each tier in a block. Regardless of the definition of unit, the Inspector General found Clinton often failed to comply with the requirement that “a number” of cells be searched each day. Prison-wide, this requirement was not met 54 percent of time during the period June 1, 2014 through June 5, 2015. Non-compliance was higher in the Honor Block, where the requirement was not met on 322, or 87 percent, of the 370 days during the same period. On six days during this period, no Honor Block cells were searched; on 316 days, only one cell was searched. Clinton’s procedures were devised to “provide equality for all inmates being frisked over an extended period of time.” In theory, this process prevents the targeting of specific cells or inmates. However, the Inspector General found that procedural flaws undermined this intended equality. Prior to the escape, the process for cell searches at Clinton began when a facility administrative employee utilized a computer to generate a random list containing one cell per company in each block. The list was provided to block sergeants who, employing their discretion, selected particular cells from the list for searches, which were then performed by correction officers. This discretion, which involved sergeants targeting certain cells and ignoring others, potentially injected personal bias into a process designed to be objective. In addition, the process did not track which cells had been searched so they could be eliminated from the pool of cells used to create the list for subsequent searches. Absent such tracking, certain inmates’ cells went unsearched while others were searched multiple times during the same period. Moreover, a number of cells were not included in the pool, therefore 103 never subject to random search. These deficiencies resulted in 295 cells throughout the facility not being searched at all during the period June 1, 2014 to June 5, 2015. The Honor Bock contains 192 cells, of which 174 are occupied by inmates and 18 are used as showers, toilets, or utility closets. In the year prior the escape, 32 of the cells were not searched, including the cell from which Sweat escaped. In contrast, during the same period some cells were searched as many as nine times. Further evidence of the disparity of cell searches was revealed by the Inspector General’s analysis of which cells in each company of the Honor Block were searched. As reflected in the chart below, cells in 6 Company were searched far less frequently than cells in other companies of the Honor Block. Notably, Matt and Sweat escaped from cells in 6 Company. Percentage of Number of Total Cell Company Cell Frisks Frisks 1 98 23% 2 114 27% 3 80 19% 4 61 14% 5 36 8% 6 34 8% Unknown 2 1% Total 425 The flaws in the process might have allowed opportunities for preventing the escape to go unrealized. Specifically, the Inspector General’s review found multiple days when the cells from which Matt or Sweat escaped were included in the random sample of cells selected. However, sergeants chose to search different cells even though the cells they selected had been searched more recently and frequently than Matt’s or Sweat’s cells. For example, on May 22, 2015, two weeks before the escape, Sweat’s cell was one of six cells in the Honor Block randomly selected by computer. However, the sergeant on duty chose 104 to search a different cell even though that cell had been searched the day before, whereas the cell occupied by Sweat had not been searched since at least the end of 2013. An opportunity to search Sweat’s cell had also occurred earlier, on March 26, 2015, but in that instance the cell searched instead of Sweat’s had been searched twice within the prior two months. According to Sweat, he started cutting the hole in his cell wall in mid-February 2015 and completed the hole three to four weeks later. Thus, had his cell been searched on either of the above mentioned dates, the breach might have been detected and the escape foiled. From February 2015 to the date of the escape, Matt’s cell was among the six cells randomly selected for search on at least nine dates. On all but one day, the sergeant chose a different cell to be searched. On March 10, 2015, the cell searched instead of Matt’s had been searched four days prior, yet at the time Matt’s cell hadn’t been searched once since at least the end of 2013. On February 5, 2015, the cell chosen had been searched eight times since January 1, 2014, while Matt’s had not been searched once during that time. Hole in Wall Not Detected in Search of Matt’s Cell On March 21, 2015, Matt’s cell was again selected, and, according to records, a search was performed by Correction Officer Patrick Allen. When questioned by the Inspector General, Allen stated he did not specifically recall searching Matt’s cell, one of a number of cells he searched during that period. The purported search yielded no contraband or evidence of a breach in the cell, despite Matt having already cut through the back wall. In his testimony to the Inspector General, Allen stated that in conducting a cell search he performed only a “visual inspection:” “I’ll start at the bed, look under, you know, move the mattress, look through whatever is on the bed and then at that point, since I cleared the bed I can start putting whatever I’ve looked through . . . on the bed knowing that everything on the bed has been searched . . . I’m looking, you know, you’ll look through their mail, make sure there’s no gang material. You’re looking for weapons. You’re looking for illegal drugs.” Asked if he ever checked the integrity of cell bars and walls, Allen replied, “To be honest with you, I’ve never had a hammer with me to check the walls or the bars.” The following exchange then occurred: Q: [T]hen specifically to the vent in the back, you would go try to pull the vent out or see if there was anything hiding in the vent holes or anything? 105 A: No, sir. The DOCCS directive provides no specific guidance on how a correction officer should conduct a cell search. Allen noted that “they briefly go over” cell search techniques in the DOCCS training academy . Other officers testified that they did not check the integrity of cell walls during searches. More troubling, this investigation obtained evidence that reported cell searches might not have in fact always occurred. Sweat, for instance, was puzzled when the Inspector General questioned him about the purported search of Matt’s cell. According to Sweat, “[I]n March, I would have seen it. I don’t remember anybody searching his cell.” Both Sweat and Correction Officer Eugene Palmer stated that Matt certainly would have mentioned to them a search of his cell, but did not. Palmer further testified that officers on occasion would “forge” reports falsely indicating that cell searches had occurred with no contraband uncovered. A former Honor Block inmate provided testimony consistent with Palmer’s assertion. A cell search receipt found by the Inspector General purports that this inmate’s cell was searched on November 11, 2014 with no contraband found. The inmate, however, testified, “I haven’t had my cell searched once.” According to him, an inmate would know when his cell had been searched, even if he was not present, because his personal items would be placed on his bed along with a receipt indicating whether contraband was or was not found. Sweat concurred with the inmate’s statement, advising that “for the most part,” an inmate knows if his cell has been searched: “You’ll know as soon as you walk in that your cell’s searched because your stuff is all moved around [and] you get a cell search slip.” When asked if officers ever reported searches that had in fact, not occurred, Sweat stated, “I’ve actually had my cell ‘not searched – searched’ a few times.” “If the CO knows you’re not doing nothing . . . they might come in and look around and then just throw the slip down and leave,” Sweat said, adding, “If you’re a guy like me that don’t get tickets and bother anybody, they don’t pay too much attention.” Officer Patrick Allen’s report of finding no contraband in Matt’s cell was not an anomaly. In fact, the Inspector General’s analysis of all reported random cell searches in all housing units at Clinton during the 12 months prior to the escape revealed that no contraband was found in 6,665, or more than 96 percent, of the 6,894 searches. In contrast, when asked if finding contraband during cell searches is a rare event, a correction officer who is also a member 106 of Clinton’s Crisis Intervention Unit, stated, “No, not at all . . . If you do your job, you’re going to find contraband in every cell search you do.” DOCCS requires cells to be randomly searched within a specific period established by a facility’s deputy superintendent for security or equivalent. However, Clinton’s policies do not identify a specific timeframe in which an inmate’s cell should be searched. The Inspector General also found that cell searches were not always properly documented and occurred during predictable times. On January 24, 2015, Sweat swapped cells with another inmate, moving from cell A6-16 to A6-23, the cell from which he escaped. Clinton policy requires that both the cell being vacated and the cell being occupied are searched prior to the swap. While the cell Sweat vacated was searched the day before the move, the cell he entered was not. The Inspector General received testimony that vacated cells were merely cleaned by inmate porters prior to being reoccupied. DOCCS and Clinton policy both require officers in housing blocks to maintain logs of all cell searches. In addition to a log entry, correction officers conducting cell searches are required by DOCCS directive to document the results on a “Contraband Receipt,” listing all prohibited items found or the absence of same. The Inspector General found discrepancies between Contraband Receipts and log entries, raising doubt as to whether purported cell searches had actually been conducted. Indeed, Clinton security staff failed to log at least 1,988 searches for which a Contraband Receipt existed, while 188 log entries lacked a corresponding Contraband Receipt. Included in the 1,988 unlogged cell searches were 81 searches that identified contraband. Sergeants assigned to housing blocks are required to conduct weekly inspections of logs to ensure all scheduled and unscheduled cell searches were completed and properly recorded. The Inspector General found that in most instances, sergeants or higher ranking officers signed the log each week, indicating their review of the same. However, given the nearly 2,000 searches not logged, it is clear that sergeants or superior officers did not properly review logs. The Inspector General also found correction officers frequently failed to report the times of cell searches, contrary to policy. Of the 6,894 Block cell searches reviewed, Clinton officers did not report the time in 3,433, or 50 percent, of the searches. When officers identified the time a cell search occurred, the Inspector General found the searches were performed during predictable times. Of the 231 Honor Block cell searches with a time noted, 219, or 94 percent, 107 occurred on the 7 a.m. to 3 p.m. shift. More specifically, 191, or 82 percent, occurred between 8 a.m. and 10 a.m., while 217, or 94 percent, occurred between 7 a.m. and noon. As the times of the searches were so predictable, an observant inmate could hide contraband during the times a search was most likely. Based on a review of 354 cells searches from June 1, 2014 to June 5, 2015 for which times were reported, the Inspector General determined that many searches were conducted hastily. Of the 354 searches, 175 took 20 minutes or less to complete, including 80 that were conducted in under 10 minutes. The average length of the eight searches conducted by Allen, the officer who searched Matt’s cell on March 21, 2015, was less than eight minutes. On June 1, 2015, in response to the melee that occurred in the main yard the day before, two correction officers each documented having conducted at least 20 cell searches during their eight-hour shift. Cell/Razor and Catwalk Inspections to Ensure Cell Integrity Since at least 2006, Clinton required security staff to conduct weekly “Cell/Razor Inspections.” The requirement was established pursuant to an “Interdepartmental Memorandum” that included a form to be completed and signed by the officer conducting the inspection. In addition to retrieving an inmate’s used razor and providing him a new one, as well as checking the inmate identification card, the form required the officer to attest to the following: “I have visually inspected all cells on ____ company; to ensure cell integrity, I have inspected each cell with attention given to cell bars, floors, vents, walls and rear of cell from catwalk. All appear secure with any discrepancies noted. . . .” A second officer was required to sign the memorandum acknowledging: As documented, the above cell inspections have been completed and a razor/I.D. Card/cell location inspection done on all companies. I also ensure that proper block log book entries have been made. These inspections have been completed on the scheduled day and in a timely fashion so as to allow review for completion. The Inspector General found that, despite these explicit requirements and signed acknowledgements, inspection of the rear of the cell from the catwalk did not take place. At least nine correction officers who conducted the inspections and signed the acknowledgements testified that they did not examine the rear of the cell from the catwalk. Indeed, a number of the officers indicated that they were not even aware that the requirement was included in the form, 108 or that they had not read the form prior to signing it. Officers further stated that they were not trained in conducting these inspections. The failure to conduct catwalk inspections represents a serious security lapse that contributed to the escape of Sweat and Matt. A proper check of “cell integrity” through an examination of cell “vents” and the “rear of cell from catwalk,” as required, most certainly would have detected the holes around the vents in the rear walls of Sweat’s and Matt’s cells and foiled the escape. Tunnel Inspections Prior to 1990, Clinton’s sprawling subterranean level, consisting of numerous tunnels, was inspected on a monthly basis, according to a veteran correction officer. The inspections, the officer stated, required a full day to complete. The officer said the inspections ceased in 1990 due to concerns about the presence of asbestos in the tunnels’ confined spaces. Following the completion of an asbestos abatement project in 1995, inspections resumed, but only on an annual basis, according to the officer. First Deputy Superintendent Donald Quinn testified that soon after assuming his position in April 2014, he instituted alternating “quarterly” inspections of the tunnels beneath the main and annex sections of the prison by Correctional Emergency Response Team members. However, the Inspector General’s investigation revealed only two subsequent tunnel inspections that were reported to have been conducted: a September, 24, 2014 inspection in the main section and a March 2, 2015 inspection in the annex. No evidence shows any additional inspections. The Inspector General questions the thoroughness of the reported inspection of the tunnels under the main section of Clinton, given Sweat’s testimony that he observed a “thick” layer of dust and dirt on the floor in an area below C-Block undisturbed by any recent activity. A quarterly tunnel inspection program, if implemented, would have resulted in an inspection of the tunnels under the main section of the prison in late March 2015. By this time, according to Sweat, he had cut out of his cell, explored the tunnels, cleared a passage between BBlock and C-Block, and cut the bolts on a floor plate he believed might provide access to a sewer line. It is probable that a thorough tunnel inspection at that time would have detected Sweat’s handiwork and prevented the escape. 109 Tool Control The control and use of tools at Clinton is governed by DOCCS and Clinton policy. The policy applies to outside contractors’ tools as well as tools in the prison inventory. Policy defines as “extremely hazardous” or “Class A” those tools “most likely to be used in an escape, used as weapons, or used as a means to manufacture weapons capable of causing death or serious injury.” The directive states that “extremely hazardous tools,” which include power nailers, electric jack hammers, and cutting torches, among others, must be stored in the prison arsenal at the end of each workday. “Class A” tools, which include power tools such as reciprocating saws and grinders, may be stored in a “locked room, secured with a heavy wire enclosure, or placed in an appropriate secured cabinet.” Tools that utilize blades or disks may be stored with one blade or disk installed in the tool; spare blades and disks must be removed from the storage area. Contractor tools must be inventoried, with a copy of the inventory remaining at the storage site and a copy forwarded to the tool control officer. Missing or misplaced tools must be reported immediately to security staff. When an outside contractor is used for work within the prison, Clinton security staff conduct a background check on all of the contractor’s employees who will be on-site. The contractor is also required to provide a written inventory of tools used on the project. During spring 2015, a contractor performing renovations to showers in the housing blocks at Clinton maintained a “gang box” in an enclosed area beneath a walkway connecting Band C-Blocks to D- and E-Blocks. This area is accessible from other underground parts of the prison and at ground level only through a locked door. The contractor used the gang box to store Class A and other tools, only some of which were listed on its inventory. The box purportedly was locked at the end of each workday. As described earlier in this report, Sweat came upon the box while seeking an escape route under the prison. Sweat said he initially found an eight-pound sledge hammer outside the box that he used to break through the brick wall between B- and C-Blocks and the Industry Building. In violation of tool control policy, the hammer was not secured. Later, according to Sweat, he picked the lock on the box and took a number of tools and other items he used in the escape. In his attempt to breach the prison’s main wall, he took a two-pound sledge hammer and a steel punch, both of which were listed on the inventory. Sweat stated he returned both tools to the box each night, but at one point broke the punch and discarded it. If Sweat’s testimony is 110 credited, the fact that no “Lost/Missing Tool Report” was filed regarding the punch constituted a violation of policy. Sweat said he also took from the box two disposable breathing masks and an LED light, which he did not return. There is no record of any reports to security staff regarding breathing masks or an LED light disappearing from a gang box during the first half of 2015. In addition, Sweat said he observed in the gang box a number of spare grinding disks, which, in violation of policy, should have been removed daily. Metal Detectors Clinton operates six magnetometers, or metal detectors, to screen for concealed weapons or other metallic contraband. In addition to the device at the front gate (discussed previously), metal detectors are located in corridors through which inmates are transported to Industry, the infirmary, the recreation yard, mess hall, and housing blocks. Prior to passing through a metal detector, inmates are instructed to remove all metal objects from their pockets as well as their belts and watches. If the presence of metal is detected, security staff will use a hand-held magnetometer (known as a wand) to locate the metal or conduct a manual pat frisk. In the event the metal still cannot be found, a BOSS (Body Orifice Security Scanner) Chair is utilized to detect items hidden within an inmate’s body. Pursuant to DOCCS policy, inmates “may” be subjected to a metal detector search when moving to and from work, housing, and program areas, in conjunction with a pat frisk, or as directed by security staff, among other reasons. Indeed, the Inspector General’s investigation found that in many instances inmates move from one area of the facility to another without passing through a metal detector. Most notably, inmates moving from breakfast to the tailor shops and from the tailor shops to the mess hall for lunch are not subjected to metal detector scan. However, all inmates returning from Industry to their housing units at the end of the work day are required, per practice, to pass through the metal detector. There are also instances when individual inmates moving through the facility are not required to pass through a metal detector because they are under the control and supervision of an escort officer. Such escorts are not uncommon and occur for a variety of reasons, including instances when inmates use the package room or require medical attention in the prison infirmary. The failure to require inmates to pass through a metal detector while under escort provides an opportunity for inmates to move contraband throughout the prison, endangering staff and other inmates. 111 Several inmates provided statements to the State Police describing their observations of Palmer’s and other officers’ practices in such circumstances. For example, one inmate recalled on a number of occasions seeing Palmer carrying a “large brown paper bag” of Matt’s from the package room. According to this inmate, after Matt passed through the metal detector, Palmer handed him the bag, which Matt then carried the rest of the way to his cell. A second inmate similarly stated that Palmer bypassed the metal detector when escorting Matt from the tailor shop to the Honor Block. Indeed, this lackadaisical approach to inmate escort security contributed to the escape of Matt and Sweat. The evidence indicates that Matt, in February 2015, was able to transport six hacksaw blades, smuggled to him by Mitchell, from Tailor Shop 1 to his cell in the Honor Block by taping them to his torso. The investigation found evidence that Matt bypassed the metal detector in the B-Block corridor during escort, almost certainly by Palmer, while returning directly to his cell from the shop or indirectly from an infirmary visit. Utility Markings on Industry Building Wall During the initial on-site examination at Clinton on June 18, the Inspector General observed a number of utility markings on the exterior wall of the Industry Building clearly visible from housing blocks and outside areas where inmates regularly walk. The markings indicate specific distances from the wall to the location of underground sewer, electrical, and water lines. These markings could provide inmates with information that might facilitate escape attempts. Partially obscured utility markings on Industry Building wall are visible to inmates (Inspector General photographs) 112 At the time of the on-site visit, concerns about the presence of the markings were reported to Clinton management. Upon a visit to the prison on June 26, these markings had been painted over, but were still largely legible. Ineffective Supervision and Mismanagement in the Tailor Shops From at least 2012, Mitchell’s improper interactions with inmates in the tailor shops were known to her civilian supervisors and observed by correction officers assigned to ensure security in the shops, yet no effective action was taken to address her conduct. In Tailor Shop 1, where Mitchell worked from November 2013 until the day of the escape, civilian managers and security personnel failed to enforce rules governing staff-inmate interaction. Under this inadequate supervision, Mitchell’s improper actions resulted in her developing close personal relationships with Sweat and Matt, which, in turn, prompted her to abet them in their escape plan. Equally troubling, Mitchell’s many criminal acts over a long period, including smuggling escape tools and exchanging illicit information with Sweat and Matt, went unnoticed by her supervisors and correction officers. Civilian Employee and Inmate Standards of Conduct in the Tailor Shops Multiple DOCCS and Clinton policies govern civilian employee and inmate conduct in the tailor shops. A DOCCS policy forbids “inappropriate relationships” between staff and inmates, in Industry shops and elsewhere; the DOCCS employee manual states that no employee shall engage in “any conversation, communication . . . or relationship with any inmate . . . which is not necessary or proper for the discharge of the employee’s duties.” Similarly, other sections of the manual instruct DOCCS employees to “maintain a quiet, firm demeanor in their contacts with inmates with no undue familiarity” and to refrain from “extending to any inmate any favor or privilege of diet, clothing . . . or of any other nature not common to all.” A separate DOCCS policy describes the proper operation of Corcraft facilities; that policy prohibits personal items in the tailor shops, as well as cooking in the shops. Clinton also has its own operations manual for industry facilities. Among other rules, Clinton’s operations manual requires inmates to stay in their “assigned work area,” prohibits “personal work” on shop machines, and states that “no reading materials are to be brought to the shop and no reading is allowed.” 113 Joyce Mitchell’s Arrival at Clinton Joyce Mitchell began her employment at Clinton in 2008 as an industrial training supervisor, a civilian position in Corcraft’s apparel manufacturing operation. She initially worked as a “relief” employee in the Industry stockroom and covered staff absences in various shops. In 2011, she was assigned to the Assessment Preparation Program Unit tailor shop, but was removed from that position and returned to relief status in January 2013. In November 2013, she was assigned to Tailor Shop 1, where she remained until the day of the escape. Since 2005, Mitchell’s husband, Lyle Mitchell, has been employed at Clinton as an industrial training supervisor. Beginning as early as 2012, supervisors and coworkers observed Mitchell interacting inappropriately with inmates. The then senior industrial superintendent, or head of Industry, was also concerned that Mitchell was inflating her evaluations of inmates and failing to enforce a rule that inmates must only punch their own time cards, among other management problems. The senior industrial superintendent testified that she discussed Mitchell’s performance problems with her on several occasions. Moreover, the senior industrial superintendent testified that she discussed her concerns about Mitchell with then-Clinton Superintendent Thomas LaValley repeatedly, but was discouraged by the results. In one meeting, according to the senior industrial superintendent, LaValley advised, “You have to be very careful what you do, because they’re going to file a grievance on us,” referring both to Mitchell and her husband. The senior industrial superintendent felt stymied, believing no action could be taken “until [Mitchell] actually did something,” that is, commit a serious act of misconduct. LaValley recalled his discussions with the senior industrial superintendent as mostly concerned with her plan for regularly rotating industrial training supervisors among shops. The senior industrial superintendent acknowledged promoting such a plan because “I didn’t want civilians in the [same] shops for years and years. That’s where you get into trouble.” No such plan was implemented. Assistant Industrial Superintendent Jay Lamb also noted the Mitchells’ reaction to criticism. When Mitchell and her husband were displeased, Lamb testified, they would “start a storm.” Mitchell, for her part, was emboldened to continue her pattern of conduct. Despite concerns about Mitchell’s performance, her annual evaluations from the beginning of her employment at DOCCS until March 2012 were uniformly positive. Mitchell’s March 8, 2012 evaluation gives the first hint of trouble with Mitchell’s performance. That 114 evaluation was prepared by Safford, the general industrial training supervisor, and Lamb, and approved by the industrial training superintendent. While Mitchell was still rated “Satisfactory,” the reviewers noted that, “[s]he needs to work on better communication with the Production Control Supervisor.” On October 17, 2012, after noting that problems were continuing, the senior industrial superintendent issued Mitchell a counseling memorandum. Mitchell was defiant, writing a letter of complaint a week later to LaValley. Also in late 2012, the senior industrial superintendent began receiving, at her request, daily emails concerning shop issues from supervisors. Many of these emails reported inappropriate conduct by Mitchell, including disrespect toward supervisors and improper interaction with inmates. For example, a December 14, 2012, email from the general industrial training supervisor reported that Mitchell allowed inmates to have reading materials at their work stations, a rule violation, and that Mitchell responded rudely when asked to address the situation. A January 2013 email from Safford described observing Mitchell “with inmates in her personal space.” A month later, an email reported Mitchell “talking to inmates about personal things.” Other emails reported similar behavior. According to the senior industrial superintendent, Mitchell also was discussed at nearly every meeting of the tailor shop supervisors. Based on the general industrial training supervisor’s email, the senior industrial superintendent said, Mitchell should have been disciplined. However, the senior industrial superintendent did not take this action, likely mindful of Mitchell’s reaction to the counseling memorandum two months earlier. The senior industrial superintendent did, however, remove Mitchell from her position in the APPU tailor shop on January 31, 2013, returning her to “relief” status. A March 2013 performance evaluation of Mitchell cited continuing problems in the tailor shop as a basis for this action. In response, on March 19, 2013, Mitchell filed a complaint with DOCCS’s Office of Diversity Management claiming harassment and unfair treatment by her supervisors. After an investigation, Diversity Management concluded the complaint was baseless. Mitchell Assigned to Tailor Shop 1 Despite the concerns about her conduct, Mitchell was assigned to Tailor Shop 1 on a permanent basis in November 2013. The then senior industrial superintendent testified she was reluctant to appoint Mitchell to this position, but felt there was no option due to staff shortages and production demands. Explaining why she took this step, the senior industrial superintendent 115 stated, “[T]here was no one else there. They’re short bodies . . . and can’t hire, and you got to get your production out. So . . . the lesser of two evils . . . You had to put her back in the shop.” Tailor Shop 1 is a large open room with individual work stations currently staffed with approximately 50 inmates. As in other shops, an industrial training supervisor, a civilian employee, oversees production by inmate workers in the shop. Industrial training supervisors report to general industrial training supervisors, who report to the assistant industrial superintendent. Quality control supervisors also roam between the various shops. A senior industrial superintendent, who manages all Industry staff, reports both to the Clinton superintendent and a Corcraft manager in Albany. Civilian staff’s normal hours of work are 7:45 a.m. to 3:45 p.m. Monday through Friday; inmates complete their work day at about 3:10 p.m. Unlike security staff, civilian employees do not “bid” for specific posts, but are assigned to positions at the discretion of Industry management. Tailor shop security is the responsibility of a correction officer whose permanent post is in the shop and who is required to be there whenever inmates are present. The officer and the civilian industrial training supervisor are assigned desks next to one another on a raised platform in front of, and facing, the inmate work stations. An escort officer accompanies inmates from their housing units to the shop in the morning and back in the afternoon, as well as when inmates are called out of the shop for a visitor, package pickup, medical appointment, or other reasons. The shop’s assigned officer escorts inmates to and from the mess hall for a 30-minute lunch break at mid-day. The industrial training supervisor is allowed to eat lunch alone in the shop. According to testimony from civilian staff, industrial training supervisors are permitted to use a microwave oven, electric skillet, or slow cooker in the shops to prepare or re-heat food, despite the DOCCS directive prohibiting cooking in the shops. Soon after Mitchell’s assignment to Tailor Shop 1, the senior industrial superintendent went on leave and was replaced by Scott Scholl, who had been the assistant industrial superintendent since 2008. With this change, any serious effort to scrutinize Mitchell’s performance stopped. For example, as Safford, the general industrial training supervisor, and Scholl all testified, soon after the senior industrial superintendent’s departure, the daily emails to management regarding the Grade 18s’ observations in the tailor shops ended. 116 Inadequate Supervision and Permissiveness in Tailor Shop 1 Evidence shows that from the departure of the industrial training superintendent in late 2013 until Matt’s and Sweat’s escape, permissiveness prevailed in Tailor Shop 1, and rules governing the interaction of staff and inmates were not properly enforced by either corrections officers or civilian staff. Two particularly glaring examples of the loose atmosphere in Tailor Shop 1 are Mitchell’s practice of bringing food in for inmates and Sweat’s use of his sewing skills to ingratiate himself with correction officers and civilian staff. Mitchell admitted that she brought food in for inmates in the tailor shops. She testified: A: I mean, all of the civilians, if they, instead of throwing food out, they would let an inmate have it. No, we’re not supposed to, but instead of throwing it out. But, yeah, I’ve made brownies and brought them in, but it wasn't a regular thing, just every now and then. Q: So apart from being extra food that you’re going to throw out, but you also made brownies? A: Yes. Q: And brought them in? What about fried chicken? A: Yes, they did get fried chicken too. Q: And who was that for? A: That was for Matt. When asked whether Mitchell brought food into the facility for inmates, Mitchell’s supervisors admitted to a type of willful blindness. Streeter observed that Mitchell “always” brought in more food than one person could eat ˗ including cakes, cookies, and apple pies ˗ but said he did not know what she did with it. Similarly, Safford testified that she never saw Mitchell give food to inmates, but acknowledged that Mitchell brought into the prison every day more food than she could consume for her own lunch. Sweat said Mitchell’s sharing of food with inmates was frequent. Another inmate who worked in the shop testified that the correction officer assigned to Tailor Shop 1, Allan Trombley, not only failed to intervene, but actually abetted Mitchell’s misconduct by handing out her baked goods to inmates. Further indicative of permissiveness in the tailor shop, civilian and security staff thought it acceptable to request favors of Sweat, considered the most competent sewer in Tailor Shop 1. According to Sweat: 117 “CO’s bring in their work bags for me to fix. I’ve made cases for skis . . . I’ve made cases for CO’s. I made a change purse thing for Vicki [Safford] . . . she brought me a thing because she was having a yard sale and she wanted an inside/outside pouch for money, for bills, for change, so I made her one, one of those. I fixed a ton of different things for her, civilians, for CO’s, jackets and all types of things. People wanted their jackets adjusted, their snaps put in their belt, they broke their belt or something. I said bring the belt in, I put snaps in it, using the machines and stuff.” Safford denied that Sweat sewed a personal item for her. Sweat also testified that, at the request of officers, he sewed carrying bags for flat-screen televisions “so that they could carry it in and out of the facility . . . so that they could watch football games and whatever.” Sweat recalled in detail one occasion when, at Mitchell’s request, he sewed patches on an article of clothing for a family member. As Sweat recalled, “[S]he tried to give me stuff for doing that. She’s like, ‘Oh, let me give you this, what do you want?’” Sweat stated that he never accepted payment for this work. “I would just tell them I want nothing,” he said. “Because now I’m in their favor. Because now the next time you see me, you’re not going to bother with me.” The Inspector General also found that Tailor Shop 1 logs, in which the movement of individual inmates in and out of the shop during the workday is required to be documented, were incomplete. For example, many of Matt’s escorts by Palmer out of the shop were not recorded. In addition, in many instances, the time inmates were temporarily out of the shop was not deducted from their attendance sheets. According to Sweat, inmates who left during the day did not “click out” when they left, and arranged with other inmates to punch their time cards at the end of the day. On occasions when Matt left during the day, Sweat said, Mitchell or other staff would “leave him clocked in.” For nearly the entirety of Mitchell’s time in Tailor Shop 1, Trombley was the correction officer assigned to the shop. During this investigation, the Inspector General questioned Trombley about security measures he took in Tailor Shop 1 that should have prevented or caught Mitchell’s numerous and often repeated acts of misconduct. Trombley stated that before inmates arrived in the shop in the morning, he checked the sewing boxes and drawers at the inmates’ work stations for contraband, but he didn’t search these areas after lunch. He also acknowledged that Mitchell was alone in the shop each morning before his arrival and during lunch break. “I do not know what she was doing” during these times, he stated. In fact, it was during these times that Mitchell secreted contraband in the storage box by Matt’s work station. 118 According to Palmer, a “breach of security” resulted from the fact that inmates moving from the tailor shops or other areas of the Industry Building to lunch in the mess hall were not subjected to a body frisk or required to pass through a magnetometer. Palmer stated that inmates could exploit this weakness and carry contraband from the Industry Building to the mess hall. There, he explained, they could hand the contraband to a mess hall worker who could carry it back to a housing block without being searched or scanned. “So if you wanted to bring, like, a cannon, you could do that because you didn’t have to go through the B-Bock corridor, because the time involved to frisk everybody shut down industry.” With respect to Mitchell’s sexual encounters in Tailor Shop 9, Trombley described security steps he claimed to have taken that would make such conduct impossible. According to Trombley, only a single designated inmate was allowed into the adjoining Tailor Shop 9, either alone or accompanied by Mitchell, but always under visual supervision. If the inmate was alone, Trombley said he required Mitchell to watch the inmate from the doorway between the shops while he observed Mitchell. If the inmate was accompanied by Mitchell, Trombley said he watched the two from the doorway to Tailor Shop 9. Trombley’s claims, however, are contradicted by Mitchell’s admitted trysts. In addition, an inmate testified that Trombley read a book or magazine at his desk every day. Further, the inmate told investigators that while Mitchell and Matt were alone in Tailor Shop 9 on numerous occasions, Trombley “let the shop just go” while the inmate acted as a lookout. Without naming Trombley, Mitchell testified that she had observed officers in her shop “put their feet on the desk looking in the opposite way and go to sleep.” Equally troubling, Trombley testified that he never observed the illicit passing of notes between Matt and Mitchell, which Mitchell admitted occurred daily. However this did not go unnoticed by an inmate, who reported he saw Mitchell handing Matt a note on numerous occasions. Nor, apparently, was Trombley concerned that Mitchell spent excessive amounts of time with Matt, testifying that the frequent interactions were work related, “from what I understood.” At least one inmate saw things differently. This inmate described Mitchell’s and Matt’s s involvement in the Tailor Shops: “It just blows me away that she used to leave her desk every morning and go over to Hacksaw’s [Matt’s] area by his machine…every day and spend . . . 85 percent of the time at his machine,” even relocating the inmate who sat next to Matt so that she 119 could sit there. As for oversight by Trombley and other relief officers in the shop during this time, an inmate testified, “The officer was sitting up there all the time, watching this whole thing. It was just amazing. I would shake my head.” Once again, Trombley’s negligence of his duties in the shop is obvious. Civilian supervision of Mitchell at this time was also inadequate. Bradley Streeter, Mitchell’s direct supervisor, related an incident he witnessed on January 28, 2015. According to a note Streeter made on that date: “Seven inmates out of their work areas, not working and drinking coffee. Shop very loud. [Mitchell] ignoring all this.” In addition, Streeter’s note quoted Trombley as telling him, “[Y]ou see why I’m bidding out it’s all the time.” At that time, Trombley was awaiting action on his request for transfer to a different post. Streeter took no action. Further, Streeter testified that at supervisor meetings during this period, a frequent comment was, “Matt’s up to the desk again.” Again, no action was taken. Streeter testified, “I have never directly confronted her about her [interaction] with inmates.” In addition, a correction officer occasionally assigned to Tailor Shop 1 said he observed Mitchell and Matt talking with each other for 30 minutes several times a day. This officer said he brought his concerns to Streeter and Scholl, the senior industrial superintendent, approximately a month before the escape. In response to the officer’s observations, Scholl merely asked him to keep an eye on Mitchell and Matt. Scholl’s response to the officer was representative of his complacent attitude at this time. Scholl had been the assistant industrial superintendent since 2008, so he was aware of complaints about Mitchell by staff that occurred before his 2013 promotion. He acknowledged that complaints persisted, but he didn’t view them as warranting formal action. Scholl testified, “So is Mrs. Mitchell on the radar more than others? Maybe a little bit.” However, Scholl added, “I don’t know that it ever came to me to the point where, in my opinion, I thought it needed to be put on paper or to pull her out.” Under Scholl, the daily email reports that his predecessor had used to monitor shop activity, including Mitchell’s behavior, were gradually dropped. Despite attending supervisor meetings, such as those Streeter described above, Scholl responded, “The only comment I can recall pertaining to Matt . . . Ms. Safford made a comment to me one day that Matt is running the shop . . . he’s telling [Mitchell] where to put people . . . he’s dictating how the shop is running.” But to Scholl, this information “really didn’t jump out to say that Matt was an issue.” By contrast, Safford testified that she repeatedly told Scholl about Mitchell’s 120 inappropriate interactions with inmates. Safford testified that she told Scholl that Mitchell “was giggly around them. She stood very close to them. Sometimes she would be sitting on the tables besides the machine visiting them.” Safford testified that Scholl told her on at least two occasions that he brought these concerns to Superintendent Racette, but Scholl never informed her of the outcome. Lamb testified that “[t]here was talk that we were going to move [Mitchell] out of the [Tailor] shop . . . and put her somewhere else. The problem with that is we are so understaffed we had no place to put her and it would have been a really, it was a challenge.” Indeed, both Lamb and Safford testified that because the tailor shops were understaffed, managers were frequently acting as shop supervisors – which meant that they were not providing quality control and general oversight of the shops. Scholl too acknowledged that he started assigning managers to shops shortly after his predecessor left her position at Clinton. Increased Production Pressure Against this background, Clinton’s tailor shops were experiencing increased production pressures in late 2014 and early 2015. According to Director of Correctional Industries Michael Hurt, 2014-15 was a very busy year at Clinton. Scholl testified that Clinton’s orders were 20 percent higher than normal during fiscal year 2014-15. One reason for the production increase was an increase in clothing orders from the New York City Department of Correction (NYCDOC) for its Rikers Island facilities. While Clinton has produced clothing pursuant to contracts with NYCDOC for many years, the monetary value ($1,877,682) of the items in fiscal year 2014-15 was the highest ever. As Lamb testified, not only was the late-2014 order “huge,” it was a “logistical nightmare” because NYCDOC was changing the colors of its uniforms and needed to not only provide clothing for its current inmates, but restock its supplies. Lamb and Hurt also testified that there was a delay in the receipt of raw materials needed for production, which further complicated the process. In addition, the timing of the NYCDOC orders put Corcraft staff under significant pressure during the first few months of 2015 because in April, the NYCDOC funds would lapse. According to Hurt, by spring 2015, the funding was in a “use it or lose it” situation. Corcraft staff were also conscious of the “buy-against procedure” clause inserted in the NYCDOC purchase orders. As Lamb described it, under the buy-against procedure clause, if the uniforms 121 were not delivered to NYCDOC on time and the city bought the uniforms from another entity at a higher price, Corcraft would be required to pay the difference. All of these factors prompted Scholl and Hurt to request overtime twice during the spring of 2015 – a lengthy process that put Scholl and Hurt in conflict with Racette and Clinton management, who opposed overtime even though DOCCS Assistant Commissioner Patricia LeConey eventually granted both requests. Female Attire in Shops DOCCS policy states that civilian employees “shall be . . . appropriately dressed while on duty” and “must be dressed in neat, clean attire that is in good repair and not revealing or extremely tight fitting.” Vicki-Lynn Safford, the Clinton Industry quality control supervisor, observed that inappropriate dress could become a security concern if female employees wore “tight-fitting clothing . . . low-cut shirts” because “If they’re bending over trying to show an inmate something, they’re not paying attention, they’re looking down your shirt or at your thighs if your pants are really tight.” Safford and security staff advised the Inspector General of their concerns specifically regarding attire worn by Mitchell while on duty. Safford said she remembered Correction Officer Eugene Palmer and another officer expressing concerns about Mitchell’s manner of dress. Safford testified that she personally observed a change in Mitchell’s dress and appearance during the two months before the escape. Safford testified that she “noticed that [Mitchell] was wearing make-up and lower-cut shirts and she had lost weight.” In the two weeks before the escape, Palmer testified, he “noted that her dress code had changed . . . I walked in [and saw] cleavage . . . but I didn’t bring it to anyone’s attention.” Palmer testified that Correction Officer Mary Lamar similarly observed Mitchell’s inappropriate attire at that time and reported her concerns to a shop sergeant. By contrast, Scholl testified “after the fact, comment was made, you notice [Mitchell] lost weight and she was wearing makeup, but I didn’t find that she was inappropriately dressed.” Although the general industrial training supervisor did not mention concerns specifically with Mitchell’s dress or appearance, she did express concerns with other civilian employees’ attire, and recommended that female tailor shop employees should wear smocks or uniforms “where everyone is the same.” 122 DOCCS and Clinton Management Oversight of Clinton Security DOCCS central office and prison management employ a number of means to assess conditions and operations in the prisons and direct specific actions to address problems. These include: Review of Unusual Incident Reports; issuance by the DOCCS deputy commissioner for correctional facilities of security-related memoranda to superintendents; facility site visits by DOCCS assistant commissioners; targeted audits; Security Management Assessment Review Team (SMART) inspections and reports; DOCCS Bureau of Internal Audit Annual Certifications; and internal control functions including facility quarterly reports, facility selfassessment guides, and facility Internal Control Committee quarterly meeting minutes and annual reports. In addition, the American Correctional Association (ACA), a national accrediting body, assesses prison compliance with ACA standards covering most aspects of prison operations. The Inspector General’s investigation found that despite using these myriad monitoring tools, some of which served their intended purposes, DOCCS and Clinton management failed to identify the fundamental security lapses that contributed to the June 5, 2105 escape. Unusual Incident Reports DOCCS policy requires prisons to submit to central office Unusual Incident Reports in the event of significant events. Reportable incidents include those that disrupt prison operations, involve use of chemical agents, involve use of weapons, or result in serious injury to staff or inmates, among others. Significantly, incident reports provide a means of prompt notification to central office of prison events. While incident reports are also entered into a computerized information system, DOCCS Deputy Commissioner for Correctional Facilities Joseph Bellnier testified that report data are infrequently used to identify incident trends in prisons. DOCCS Security Memoranda to Prison Superintendents Since assuming the position of DOCCS deputy commissioner for correctional facilities in 2011, Joseph Bellnier issued a number of memoranda to prison superintendents concerning security matters. The memoranda are prompted by specific incidents or serve as periodic reminders intended to ensure adherence to certain security requirements. A memorandum Bellnier issued eight weeks before the escape of Sweat and Matt is noteworthy. 123 The April 7, 2015 memorandum from Bellnier directed superintendents to take specific actions to “eliminate the possibility of escapes from our facilities.” The memorandum referenced “recent events” -- an attempted escape from Auburn Correctional Facility by an inmate who planned to flee in a load of sawdust being removed from the prison, and an attempted suicide by an inmate who security staff improperly left in an Industry area at Eastern Correctional Facility. In the memorandum, Bellnier noted the importance of compliance with “gate procedures,” “count procedures,” and the inspection of “all Industry and Maintenance areas,” and included the admonition, “Do not overlook basements, attics, tunnels, drainage access, etc.” [emphasis supplied] These are precisely the areas, among others, where security failures contributed to the escape. However, the Inspector General’s investigation found no evidence that Clinton management took any action to implement the provisions of the memorandum. Moreover, Bellnier testified that he did not require superintendents to confirm compliance with the memorandum; nor did he conduct any follow-up. Ironically, Clinton received the memorandum at the very time Sweat was at work in the tunnels under the prison. DOCCS Assistant Commissioner Facility Site Visits DOCCS also periodically conducts Facility Site Visits at all prisons to review security and others issues. A team headed by an assistant commissioner and including the prison superintendent and other executive management staff, tour the facility over the course of a day or two. The teams assess facility compliance with 50 standards, including 16 related to security. The Inspector General reviewed the reports of the two Facility Site Visits conducted at Clinton in 2014-2015 prior to the escape by then Assistant Commissioner Patricia LeConey. This review found full compliance reported for all security items that were evaluated. (Several items were not assessed.) The evaluated items included accuracy of logbooks, tool control, and contraband control. When asked by the Inspector General if the site visit reports are useful, LeConey replied they are “not really . . . because it doesn’t really say a lot.” LeConey further advised, “You don’t get a whole lot of checking done. By the time you talk to staff, you walk around, you talk to inmates. . . .” As the Inspector General’s investigation revealed deficiencies in these areas, the value of the Clinton site visits must also be questioned. 124 Notably, site visits conducted by other assistant commissioners at other maximumsecurity facilities appear to have been more substantive. For example, an assistant commissioner’s site visit at Downstate Correctional Facility in 2014 found security staff wearing civilian attire and deficiencies in perimeter wall maintenance. This assistant commissioner’s 2015 Downstate site visit reported non-compliance in tool control and logbooks, and noted he had discussed with facility staff the need to ensure proper and regular cell bar checks. Targeted Audits DOCCS central office conducts periodic audits of specific program areas within prisons. Results of the audits are communicated to the superintendent in a report. During the period 2013 until the escape in 2015, a total of 13 such audits were conducted of programs at Clinton. Areas audited included fire and safety; pharmacy; education; financial; occupational safety and health, among others. Notably, the November 2014 audit of the Special Housing Unit was the only audit directly related to security operations. This audit revealed non-compliance with security policy, specifically that captains conducted only half the number of required rounds and that correction officers failed to conduct required 30-minute rounds or did not adequately document these rounds. Of further concern, the audit report included no plan for corrective action or facility response. Security Management Assessment Response Team Inspections and Reports DOCCS convenes a Security Management Assessment Response Team (SMART) to conduct on-site evaluations at prisons. According to Bellnier, the SMART was created “in response to the rise in violence in the system” and reviews such issues as “inmate movement, officer coverage, you know . . . where were people at various times of the day.” DOCCS central office dispatched the review team to Clinton on two occasions in early 2014 to assess the level of violence in the prison and the ability of prison management to address it. The team consisted of Assistant Commissioner James O’Gorman, Crisis Intervention Unit Director Joseph Noeth, Correctional Emergency Response Team Director Colonel Michael Kirkpatrick, and Captain Robert Ball. The first review occurred over several days in February 2014 and found the prison “appears to be functioning properly” but made several findings. These included failure to secure “numerous” end gates in housing blocks, lack of security supervision on the overnight shift, and 125 ineffectiveness of the Inmate Liaison Committee resulting from its refusal to meet with the superintendent, among others. In addition, the review found “staff relationship with the executive team, specifically with the superintendent is tenuous at best.” The review further found that “status quo reigned supreme – phrases, such as, ‘it’s Clinton,’ or ‘it’s always been this way,” paint a dismal picture of leadership.” The review team returned to Clinton in April 2014 and found that several recommendations to address problems identified in the earlier review had been implemented. However, the review again noted that housing block end gates were unsecured. More significantly, the review concluded that most staff “do not trust the superintendent or the executive team” and “morale is very low and they were asking us for help.” In the wake of the two SMART reports, DOCCS appointed Steven Racette to replace Superintendent Thomas LaValley, who retired. Facility Quarterly and Annual Reports Superintendents provide information to DOCCS central office on a range of prison operations in quarterly reports in April, July, and October, and an annual report in January. The Inspector General’s investigation examined the quarterly and annual reports submitted by the Clinton superintendent from April 2013 through April 2015. The report sections on security operations vary little from quarter to quarter, typically listing current security staffing levels and overtime, as well as data on inmate grievances, Unusual Incidents, and misbehavior reports during the period. The 2014 annual report, submitted on January 27, 2015, noted, “Frisking of all areas has been increased Main and Annex to include employee areas and gate/entrance areas,” and “Facility policy is under review related to staff accountability and safety to improve security in all areas of the facility,” but included no details or results related to these purported initiatives. The quarterly report submitted on April 28, 2015, by which date Sweat and Matt had been actively working on their escape route for more than two months, noted, “Clinton continues to operate normally.” Internal Controls Clinton conducts a number of reviews of its programs, including annual Self-Assessment Guides and Internal Control Committee reports for a number of facility operations including “security control.” The security assessments are performed by Clinton plant superintendents and 126 assistant deputy superintendents and entail the review of 170 security-related items. The Inspector General reviewed the security assessments for Clinton for the period 2011-2014. Significantly, the assessors did not find a single security item to be non-compliant in any of the four years. These included the following security control questions: “Are all containers carried into or out of the facility by staff being searched?” “Are security inspections of bars, windows, gate, doors and locks done at a minimum of once a week in accordance with Directive #4910?” “Are garden hoses, extension cords, and other similar items controlled and proper length indicated?” As noted, the Inspector General’s investigation identified deficiencies in these areas, all of which contributed to the escape of Sweat and Matt. Moreover, the security self-assessments conducted at DOCCS’s other 16 maximum-security prisons during the same period also reported full compliance on all items. In light of these findings, the self-assessment program in its entirety must be judged without value. Clinton’s Internal Control Committee, which consists of employees representing all aspects of facility operations, meets quarterly to discuss such issues as prison policy and recent audits, among other matters. At each meeting, committee members are asked to identify any internal control weaknesses during the quarter. Notably, the Inspector General’s review of the minutes of the eight committee meetings conducted in 2013 and 2014 showed no internal control weaknesses were identified. Pursuant to the New York State Government Accountability, Audit and Internal Control Act, DOCCS, like all agencies, must annually certify that it has conducted an internal control risk assessment and addressed any identified risks. The results of the risk assessment are reported in a Bureau of Internal Audit Annual Certification prepared by the DOCCS Internal Control Officer. In preparing the annual certification, the Internal Control Officer relies on the aforementioned assessments, reports, and minutes to identify risks. Given the deficiencies described above, this annual certification is of limited value. The May 31, 2015 Inmate Melee and Request for a Lockdown At approximately 5 p.m. on May 31, 2015, a fight involving approximately 30 inmates erupted in the North Yard at Clinton. The melee was quelled within a minute by security staff firing three gas canisters into the yard. At the time of the incident, more than 350 inmates were 127 in the yard. No officers were hurt, but four inmates sustained injuries, the most serious a fractured leg. Immediately after the incident, a captain who was the officer of the day, was apprised by telephone and reported to the prison, where he was briefed by the watch commander. The captain was soon joined by First Deputy Superintendent Donald Quinn, Deputy Superintendent for Security Stephen Brown, and Captain David Lucia, who were also briefed on the situation. At about 9 p.m., after monitoring activities in the yard, the four met to discuss the incident, examine the files of the involved inmates, and review a video of the fight. Knowing at this time that the melee was gang-related, involved a large number of inmates, and that chemical agents had been discharged, they agreed that a full lockdown of the prison was warranted. Quinn testified that based on the information then available, a lockdown was “absolutely” required. Pursuant to DOCCS policy, a full lockdown may only be undertaken after the superintendent consults with the deputy commissioner for correctional facilities and receives authorization. Policy states that the request for full lockdown “must be clearly delineated” by the superintendent and “will be directly related to the facility’s safety, security and operations.” Policy does not require that the lockdown request be made in writing, nor that deliberations or decisions by DOCCS executive management in response to the request be documented. Quinn then conveyed the facts of the melee by telephone to Superintendent Steven Racette, who was not at the facility. Racette stated he concurred that a full lockdown was justified and instructed Quinn, on his behalf, to contact DOCCS central office to request authorization for such an action. At about 9 p.m. and again at about 10 p.m., Quinn called then Assistant Commissioner Patricia LeConey, who oversees the “hub” of prisons that includes Clinton. Quinn advised LeConey that the fight was sparked by a Bloods-Muslim dispute, involved more than 30 inmates, was quickly quelled after gas was deployed, and that seven inmates suffered minor injuries. LeConey responded that she would discuss the request with her superiors and have an answer for Racette and Quinn in the morning. In the meantime, LeConey approved Clinton management’s plan to conduct a limited lockdown and search of several housing blocks and other areas of the prison the next morning. Following her conversations with Quinn, LeConey consulted with DOCCS Crisis Intervention Unit Director Joseph Noeth, requesting that Noeth review recent data on violence at Clinton. Noeth testified that he compared Clinton incident reports on “assaults on staff, assaults 128 on inmates, drugs, weapons” for the periods December 2013-May 2014 and December 2014May 2015. The data showed, according to Noeth, that Clinton “was operating better” and “going in a good direction” in the later period. Based on the information provided by Noeth, LeConey agreed that “the numbers looked good.” The Inspector General found that Noeth’s characterization of the incidence of violent incidents at Clinton was largely correct. While the number of assaults on staff, assaults on inmates, and drug seizures were lower in the later period, the number of weapons seizures was higher. LeConey apprised Joseph Bellnier, DOCCS deputy commissioner for correctional facilities, of the facts of the melee as reported to her as well as Noeth’s analysis. According to Bellnier, after considering this information, he concluded the altercation was “pretty minimal,” further stating: “The response was excellent. The deployment of the chemical agents was spot on. [The fighting] broke instantly. And minimal force, if any. And minimal injuries. And not a lot of weapons recovered.” As Bellnier stated, “We didn’t see anything . . . that would rise to the level of overall facility search,” including the fact that Clinton’s most recent previous lockdown was in 2013. Bellnier testified that he apprised DOCCS Acting Commissioner Anthony Annucci of the lockdown request and his recommendation that the request be denied. As planned, at about 8 a.m. on Monday, June 1, LeConey spoke with Racette. During this conversation, according to Racette, he reported that the previous day’s incident was “a very large disturbance and we’ve been having some disturbances in the yard prior to this date and I was concerned that it was escalating and the best way to cool it down was to have a [full lockdown].” LeConey advised Racette that a full lockdown would not be authorized. Apart from the requirement that a request for a lockdown must relate to a prison’s safety and security, the directive does not delineate the events or conditions warranting a lockdown. As Bellnier testified, the decision to implement a lockdown or not is “a judgment call” based on “the facts … as they’re known at the time” as well as “experience and your gut.” LeConey stated that the decision is driven by the “indicators” – data regarding assaults on staff and inmates, weapons recovered, and contraband found. Noeth stated he considered the most important factors to be injuries to the inmates or staff; weapons used or recovered, and the likelihood of the incident continuing. Bellnier, LeConey, and Noeth all testified that overtime costs or lost production in Clinton’s tailor shops resulting from a lockdown were not considerations. 129 After the decision was communicated, LeConey did not follow up on the situation at Clinton, and Racette did not provide further information. When asked if there was any process for additional information to be provided to her, LeConey stated the “superintendent would be the one to do that” and “the onus is on the superintendent to advocate” for his own facility. She agreed, however, that it would have been prudent for her to contact Racette. Asked if he considered renewing his request for a lockdown, Racette stated, “No, once I was told ‘no’ . . . I have been told ‘no.’” OSI’s Investigations of Mitchell’s January 2015 Complaint Almost immediately after Sweat resumed working in Industry, assigned to Tailor Shop 8, rumors of an intimate relationship between Sweat and Mitchell again purportedly surfaced. In a January 23, 2015 complaint to Superintendent Racette, Mitchell claimed that on January 20, inmates in Tailor Shop 1 “informed me that they had heard from other industry workers that [Vicki] Safford was suggesting that there had been intimate relationship between myself and inmate Sweat.” Mitchell further claimed that on January 22, Correction Officer Eugene Palmer “informed me that inmates had come to him with the same insinuations.” In the memorandum, Mitchell denied a relationship with Sweat and stated that the rumor “was putting my life and job in jeopardy.” On February 3, 2015, Clinton administration referred Mitchell’s complaint to the DOCCS OSI, which commenced an investigation. OSI closed its investigation on May 14, 2015, concluding that Mitchell’s complaint was unfounded. During the period February 5-9, an OSI investigator interviewed Sweat; Mitchell; Safford; the industrial training supervisor in Tailor Shop 8, the civilian supervisor in Tailor Shop 8; and Scott Scholl, the head of Industry. Sweat, like Mitchell, blamed Safford, stating, “I was told by other inmates that Ms. Safford was pissed off because I was working in the tailor shops again, and they overheard her telling other staff that Mrs. Mitchell and I were having a relationship.” Safford denied telling anyone that such a relationship existed. Both Mitchell and Sweat denied any involvement with one another. The investigator stated that he found Mitchell’s and Sweat’s denials credible. Although not noted in the OSI report, the investigator said he reviewed Sweat’s telephone call history but found nothing unusual. In her interview, the industrial training supervisor advised the investigator of past concerns of a relationship between Mitchell and Sweat, specifically that Sweat had been removed from Tailor Shop 1 because Mitchell was “too friendly with him.” The industrial 130 training supervisor also stated she had been directed to report to Industry management if Mitchell went near Tailor Shop 8, where Sweat recently had been reassigned. Scholl told the investigator he did not believe there was an improper relationship between Mitchell and Sweat, nor that Safford had spread a rumor of such a relationship. However, Scholl stated that Sweat had been removed from Tailor Shop 1 by Captain David Lucia because “it felt like he was getting too comfortable there,” and further advised that Mitchell had “requested to get Sweat reassigned to Tailor Shop 1” following his removal. In addition, Scholl advised that Bradley Streeter, Mitchell’s direct supervisor, might also have been a source of the rumors. However, the investigator did not interview Lucia, Streeter, or Trombley, the officer who provided security in Tailor Shop 1. Further, a search of Sweat’s cell was not conducted. Such a search might have uncovered the security star-bits Mitchell had smuggled to Sweat a week or so earlier and thereby foiled the escape. When questioned by the Inspector General, the investigator explained his rationale for not exploring the underlying relationship between Mitchell and Sweat. According to the investigator, he initially met with Superintendent Racette, who characterized the issue as “staff harassing other staff” with inadequate supervision by Scholl. The investigator stated that Racette’s description of the issue as essentially a personnel dispute, while expressing no concerns about an inappropriate relationship between Mitchell and Sweat, “did take away my focus from the unauthorized relationship . . . it threw me off my game.” Moreover, the investigator stated that he didn’t suspect that an improper relationship existed between Mitchell and Sweat because it would make no sense for Mitchell to file a complaint drawing attention to that very relationship. In fact, Mitchell was deceitful when interviewed by the investigator in February 2015. Mitchell’s statement to the investigator that “none of this is true; I have never been involved in any type of relationship with inmate Sweat” is clearly false. By this time, Mitchell had already begun smuggling escape tools to Sweat and exchanging notes with him of a personal or sexually intimate nature. Further, Mitchell was untruthful in telling the investigator, according to his interview notes, that “Scholl has never spoke [sic] to me about . . . how I interact w/ inmates.” As noted earlier in this report, Scholl had counseled Mitchell about her interaction specifically with Sweat after the furor resulting from the anonymous note in July 2014. 131 On June 7 and 8, shortly after the escape, OSI re-opened its investigation. OSI assigned a senior investigator to conduct additional investigation into the allegations regarding Mitchell’s relationship with Sweat. The senior investigator re-interviewed Safford, the industrial training supervisor assigned to Tailor Shop 8, and Scholl. Significantly, all three now provided information they had failed to disclose in their interviews in February. Safford now recalled she had “observed Mitchell to be overly friendly with the inmates . . . and takes sides with the inmates over staff and feels too comfortable with the inmates.” Scholl now advised that he “had to speak to [Mitchell] about being too comfortable with inmates” after Sweat’s removal from the Tailor Shop 1. The industrial training supervisor now stated that Mitchell was “extremely friendly with inmates and would rather socialize with them than coworkers.” After his two-day inquiry, the senior investigator prepared a draft report which did note a number of deficiencies in the earlier investigation: “The original investigation does not indicate if a mail watch was placed on Inmate Sweat or if there were any inmate telephone calls that were reviewed. It also appears that the cell of Inmate Sweat was not frisked for any contraband or corroborating evidence. Also there is no indication that a subpoena was issued for the review of Ms. Mitchell’s cellular phone or Facebook records as a means to find any evidence that may support that there was an inappropriate relationship between Ms. Mitchell and inmates.” The report of re-investigation concluded that Mitchell had “overly friendly” relationships with inmates, Sweat in particular, and that while coworkers and supervisors were aware of this situation, “very little was done to address and correct her behavior and attitude.” The report also concluded that Palmer “was probably too close to Inmate Sweat as evidenced by his interest in having Inmate Sweat re-instated at the Tailor Shop even while he had concerns that Ms. Mitchell was overly interested in Inmate Sweat.” This investigation, however, was still deficient. For example, when interviewed by the Inspector General, the senior investigator admitted that he should have interviewed Trombley, an obviously important witness, but failed to do so. In fact, the senior investigator failed to seek to interview any correction officers in his follow-up inquiry, although he did communicate with Palmer when Palmer approached him asking questions. The senior investigator attributed this to being rushed due to the circumstances under which he was working. 132 DOCCS Chief of Investigations Stephen Maher acknowledged that the senior investigator’s inquiry was not comprehensive and testified that he never deemed the senior investigator’s unsigned report to be final: “There were lots of other things going on . . . and we just never got back to doing a full-blown investigation.” But Maher also testified that the purpose of conducting this new investigation was both “to get additional information about Joyce Mitchell” and “just as importantly to find out what we should have done at the time [in the first investigation].” Unfortunately, the senior investigator’s inquiry did neither. By failing to conduct a more thorough investigation, the senior investigator neither fully accounted for the prior investigation’s deficiencies nor conducted all necessary interviews to shed more light on how Mitchell facilitated the escape and what the escapees’ plans were to elude capture. The 2003 Escape of Two Convicted Murderers from Elmira Correctional Facility On July 7, 2003, convicted murderers Timothy Vail and Timothy Morgan escaped from DOCCS’s maximum-security Elmira Correctional Facility. Both inmates were apprehended the following day. DOCCS conducted an internal investigation into the escape, which was the first escape from Elmira since 1984 and the first from any of the state’s maximum-security prisons since 1994. As described in DOCCS’s March 19, 2004 report of investigation, the escape itself and the breakdowns in security that contributed to it bear striking similarities to the circumstances of the escape of Matt and Sweat from Clinton 11 years later. Vail and Morgan began planning their escape in late February or early March 2003. The escape plan devised by Vail entailed gaining access to the prison roof, from which they would descend to the ground outside the prison using a handmade rope. At Vail’s direction, Morgan, who occupied a double-cell on the top floor of F-Block, told his cellmate to request reassignment to a different cell. Morgan and Vail then requested and received permission to share Morgan’s cell. This put them in a position to gain access to the prison attic and roof through the ceiling of their cell. Vail, who worked in the prison’s carpentry shop, befriended the shop’s civilian instructor. At one point, Vail gave the instructor a painting he had made, receiving cigarettes in return. The instructor also made gifts of food to Vail, and brought into the shop a map of the Adirondacks he allowed Vail to examine. Notably, Vail later told investigators that he hoped to evade capture after the escape by hiding in the Adirondacks. 133 While assigned to the shop, Vail smuggled numerous items into his and Morgan’s cell to assist in the escape. The items included approximately 100 sheet rock screws which Vail secreted in the hollow legs of a chair the shop instructor allowed him to take to the cell. Vail smuggled a 12-pound sledge hammer head being used as a door stop in the shop by merely placing it in a net bag and carrying it back to the cell. Several pieces of a band saw blade were smuggled by Vail in a tobacco pouch he glued shut so as to appear unopened. Vail smuggled a 14-inch metal bar from a table saw by taping it to his leg. While visiting the shop one day, Morgan removed a metal piece from a planer and smuggled it into the cell hidden in his pants. Vail and Morgan were able to transport these items from the shop to their cell without discovery because they were not subjected to metal detector scans on their route. For a period of approximately four months, Vail and Morgan used the screws, blade pieces, and other items to cut a large hole through the five-inch, reinforced concrete ceiling of their cell. While one inmate worked on the ceiling, the other served as a lookout. They recorded their efforts on a calendar using smiley faces to denote days when they made significant progress. They flushed down their cell toilet the concrete chips produced by their handiwork. To hide the opening, they taped over it a piece of construction paper painted the same color as the ceiling. Towels hung from the upper inside front of the cell, in violation of facility rules but not ordered removed, partially blocked a view of the area of the ceiling where the hole was located. During this time, security staff conducted three unannounced cell searches, but failed to detect the hole in the ceiling or any contraband items. On the night of their escape, Vail and Morgan placed dummies in their beds which they had crafted from papier-mâché, flesh-toned paint, and Morgan’s own hair which Vail had cut during the previous two weeks. The two inmates had also been dieting for the prior month so they would be able to squeeze through the hole in their cell ceiling. Immediately after the 10 p.m. count, Vail and Morgan climbed through the hole into the prison attic, then through ductwork onto the roof. From there, they descended the front wall of the prison using a rope they had fashioned by tying together 11 bed sheets, including eight provided by the prison and three personally belonging to Morgan. They were able to accumulate that number of sheets because Elmira management had failed to implement a 1997 revision to DOCCS policy limiting inmates to two facility-issued sheets each. During his descent, Vail lost his grip and fell approximately 30 feet, hitting a protruding portion of the wall and landing on the 134 ground about 10 feet from the base of the wall. Having sustained shoulder and ankle injuries, Vail lay for some 15 minutes in a spot that should have been visible to the officer in Tower 1. The investigation found, however, that the tower officer was inattentive at the time. After recovering from his fall, Vail, joined by Morgan, fled undetected across the prison parking lot and lawn. The officer conducting the 2:30 a.m. and 4:30 a.m. counts failed to note the inmates were missing, and their absence was not discovered until the 6:30 a.m. master count. Vail and Morgan remained at large for less than 48 hours. At approximately 7:10 p.m. on July 8, they were apprehended by the State Police in the nearby Village of Horseheads after stealing a vehicle. The DOCCS report of investigation concluded that systemic failures at Elmira contributed significantly to the escape. According to the report: “The lapses at Elmira go further than just line staff. Elmira’s supervisors and administrators bear the responsibility for not appropriately monitoring staff performance, ensuring that departmental policies were adhered to and enforcing accountability accordingly.” * ** “The escape of inmates Timothy Vail and Timothy Morgan was avoidable. It resulted from complacency manifested in a widespread breakdown in Departmental practices, long-time policies and security procedures. The inmates recognized and took advantage of these lapses. Staff complacency allowed the inmates to identify, smuggle, and utilize contraband and other material to enable their escape.” In response to the report’s findings, Elmira management took a number of actions to address security deficiencies that contributed to the escape. These actions included: installing additional metal detectors in the prison’s shop area and requiring that all inmates are scanned upon exit from the shop; instructing staff on existing requirements for inmate counts; requiring tower officers to report hourly by telephone to the assistant watch commander; ensuring that cell searches are completed and documented by a weekly review by a captain and deputy superintendent for security; and reiterating and strengthening shop tool control. The actions taken by DOCCS central office in response to the findings of its own report were lacking. Despite clear findings of failure at the highest levels of Elmira management, DOCCS only took disciplinary action against “line staff”: the civilian shop employee, the correction officer responsible for the night count, and the tower officer. In addition, although the 135 DOCCS report concluded “there is no reason except complacency” that multiple searches of Vail’s and Morgan’s cell failed to detect the hole in the ceiling or contraband items in the cell, the officer or officers who conducted the searches were not disciplined. Significantly, no superior officer or management official was sanctioned. Even more troubling, DOCCS took insufficient action to ensure that deficiencies that contributed to the Elmira escape were not also present at other prisons. DOCCS disseminated its report of investigation to all prison superintendents shortly after its completion. The report’s conclusion noted that it was intended “to provide a self-auditing tool for all other prisons in hopes of preventing similar incidents from occurring within their perimeters.” However, DOCCS did not direct superintendents to implement any specific action or provide any response. Apart from dissemination of the report, a review of DOCCS central office written communications to superintendents in the aftermath of the Elmira escape revealed only two relevant memoranda. The first, issued 11 weeks after the escape, merely reminded superintendents to enforce longstanding policy that limited the number of bedsheets permitted in an inmate’s cell. The second, issued five months after the escape, advised superintendents of soon-to-be implemented revisions to DOCCS’s tool control policy addressing the monitoring of tool and supply inventories and the frisking of inmates to and from work areas. Importantly, no memoranda were issued regarding cell searches and night counts, critically important procedures where deficiencies contributed directly to the escape. With the exception of poor linen control, the security deficiencies identified in the Elmira escape were the very same lapses that were major contributors to the June 5, 2015 Clinton escape. If Clinton conducted any meaningful “self-auditing,” as hoped by the then DOCCS commissioner, it surely overlooked the security failures Sweat and Matt exploited. Coincidentally, Sweat was incarcerated at Elmira from August to October 2003, immediately following his murder conviction and sentencing. Arriving at Elmira a month after the events, Sweat told investigators, he became aware of the escape and recapture of Vail and Morgan “from COs” and talking with other inmates. The detail of the breakout and manhunt that Sweat recalled most clearly more than a decade later was the decision by Vail and Morgan – “dumbasses,” Sweat called them – to steal an idling van from a parking lot, resulting in their recapture minutes later. “You just escaped from prison, and you’re going to steal a car,” Sweat said. “It’s like throwing up a red flag. ‘Hey, I’m over here.’” Sweat told investigators that 136 while he and Matt were fugitives in June 2015, Matt suggested they hijack a vehicle, but Sweat talked him out of it. Although Vail was incarcerated at Clinton from September 2003 to May 2010, Sweat said they never met or spoke. Deficiencies in DOCCS Training of Security and Civilian Staff Security Staff Training New York State correction officer recruits must complete an eight-week training course at the DOCCS Training Academy in Albany. Training consists of 320 hours of coursework, including instruction in supervision of general housing, gate security, tool control, legal principles, and defensive tactics, among others. An “Attitudes in Supervision” course includes a 25-minute video entitled “Games Inmates Play,” which describes tactics inmates might use to manipulate prison personnel. Upon successful completion of the Academy program, recruits are assigned to three weeks of “On the Job Training” (OJT) at a maximum-security prison. During OJT, recruits are supervised by a Field Training Officer and assigned to an experienced officer with an interest in training. In the first two weeks of OJT, in addition to facility-specific orientation, recruits receive training in counts, frisks/handcuffing, emergency procedures, and tool and key control, among other topics. The third week of OJT is conducted at the prison where the recruit will first be stationed. Correction officers transferring to Clinton from other prisons receive two days of orientation that includes fingerprinting; receipt of identification cards, copies of handbooks, manuals, and policies; and tours of the prison. All correction officers are also mandated to complete at least 40 hours of annual training. Training is further required upon promotion. Correction officers promoted to sergeant are required to attend a two-week training course at the academy; newly promoted lieutenants and captains must complete one week of academy training. The Inspector General’s investigation revealed deficiencies in DOCCS’s training of security staff. Although newly promoted sergeants, lieutenants, and captains are required to complete either one or two weeks of academy training, records reveal many promoted officers do not do so until well after assuming their new duties. As of August 18, 2015, a total of 182 sergeants statewide had not completed training, including 83 sergeants whose promotions 137 occurred between 1995 and 2012. As of October 15, 2015, six sergeants at Clinton, all promoted between 2012 and 2015, had not received the training. According to the DOCCS training director, sergeants avoid the training by having a supervisor notify the academy that they are unavailable, and the academy lacks authority to compel attendance. Records show that only eight of 22 captains attended the most recent training. In addition, testimony obtained by the Inspector General from Clinton officers revealed a number of areas where training of officers appears to have been inadequate. For example, several officers claimed ignorance of the requirement that cell inspections conducted at the time of razor checks include an examination of cell integrity from the catwalk area. In fact, one officer testified that he didn’t even know the location of the catwalk, stating, “I just learned the other day . . . I was under the impression the catwalk was the . . . walking area in front of the cells. Now I just learned yesterday that they were referring to the catwalk as the area in in between the backs of the cells.” One officer testified to what he viewed as deficiencies in overall training: “You do two or three days of touring the facility, make sure your payroll is set, learning, you know, this is the annex, this is the main, this is where this is, that’s where that is, and then you're thrown the keys. When I came to Clinton . . . you just, I was actually thrown into it.” Civilian Employee Training DOCCS civilian employees are required to complete 40 hours of training at the time of hire to familiarize them with the facility where they are assigned and their particular job functions. Within their first year on the job, civilian employees are required to complete “Career One Training” that includes three days, or 24 hours, of Recognizing, Evaluating, Controlling, Aggressive Behavior (RECAB) training. RECAB trainers stated a significant part of the instruction is devoted to “GOTCHA” training, which focuses on how inmates attempt to manipulate employees. Specifically, instruction addresses how inmates select employee targets, whether seeking sex, drugs, weapons, or help in escape. The training includes studying actual past incidents and role playing, and requires employees to discuss and analyze such issues as the likelihood of being targeted, their work attire, permitted conversation in the presence of inmates, and means of controlling themselves and their surroundings. Every five years thereafter, civilian employees are required 138 to complete a two-day RECAB refresher course. Both trainers advised the Inspector General they believed the refresher course should be required every two to three years. A RECAB trainer advised that while officer recruits had received RECAB training at the academy in the past, this is no longer the case. Both trainers stated RECAB instruction should be offered to officer recruits. As noted, new civilian employees are required to complete “Career One Training,” which includes RECAB training, but they can complete this portion of their training at any time within the first year of their employment. Given the importance of RECAB training, both trainers opined that new civilian employees should be required to complete the training before actually beginning work in prisons. Similar to security staff, civilian employees can also delay or avoid required training at the request of a supervisor. Both trainers also suggested that civilian employees should be required to wear uniforms. 139 FINDINGS AND RECOMMENDATIONS OF THE INSPECTOR GENERAL Multiple breakdowns in Clinton security operations and DOCCS oversight contributed to the June 5 escape. To correct these failures, many changes are necessary. Of urgent importance, Clinton must ensure that fundamental security requirements are met. These requirements include effective front gate screening of all employees; diligent night counts to ensure the presence of inmates; thorough and more frequent searches of cells, catwalks, and tunnels to uncover contraband and evidence of escape planning; and strict enforcement of policy prohibiting improper interaction of staff and inmates in the tailor shops and elsewhere. DOCCS also must significantly expand the use of cameras and other electronic detection and monitoring systems. To combat what Bellnier characterized as Clinton’s “culture of carelessness,” DOCCS central office and Clinton management must implement a comprehensive program of regular security audits, with effective follow-up, to ensure compliance with the above requirements. DOCCS and Clinton management must act to counter a chronic indifference toward security and instill a sense of responsibility and accountability at all levels at Clinton. Oversight of DOCCS is Required to Ensure the Integrity of the System The nature and extent of the systemic investigatory and oversight failures that contributed to the June 5 escape call into question the ability of DOCCS to oversee itself. This need for oversight is further supported by subsequent allegations of abuse by DOCCS personnel at both Clinton and other state prisons that have emerged in the wake of the escape. Additionally, in the course of this investigation and other investigations of DOCCS, the Inspector General found inherent flaws in OSI’s structure which remain. Of serious concern, OSI’s investigative ranks largely consist of correction officers previously assigned to prisons. The investigators’ assignment to OSI can be summarily revoked by DOCCS management, resulting in their return to the prison positions they previously held. Aware of this possibility, particularly when threatened by management, investigators during the course of interviews with the Inspector General have indicated a significant reluctance to make complaints against supervisors or report problems within OSI. The structure further creates a potential conflict that could affect an investigation when OSI investigators are charged with investigating former facilities or colleagues. 140 As such, the Inspector General recommends that OSI be restructured to ensure the quality and integrity of investigations, consisting of investigators who are not subject to return to facilities as correction officers. The Inspector General further recommends that DOCCS create a specialized unit with a staff possessed with the requisite expertise to conduct and oversee investigations, including those involving the use of excessive force against inmates by DOCCS personnel, reporting directly to the Commissioner of DOCCS. Finally, the Inspector General is creating a unit specifically designed and trained to audit and monitor DOCCS and ensure the integrity of its operations, policies, and practices. In the wake of the escape, and during the course of this investigation, the Inspector General has made recommendations to DOCCS to address deficiencies and breakdowns in policies and practices that were identified. DOCCS has agreed to these recommendations and has implemented or is in the process of implementing these corrective measures. They are discussed specifically below. DOCCS has also agreed to conduct audits to ensure the proper implementation of these recommendations. Front Gate Security The Inspector General found that officers assigned to the front gate at Clinton failed to comply with policy requiring that they search the bags and containers of all employees entering and exiting the prison. Numerous staff testified, and the Inspector General observed, that such searches rarely occur. Further, although permitted by policy, employees or their bags and containers are never subjected to a metal detector scan. Properly conducted front gate security checks very likely would have deterred or detected Mitchell’s smuggling of escape tools into the prison. As a result of the Inspector General’s recommendations, DOCCS has agreed to the following: ● Front gate security staff will open and examine the contents of bags and containers of all employees entering and exiting the prison. Limits on the number and size of bags and containers will be enforced. Clear bags and containers will be required. ● Utilization of metal detectors will significantly increase. ● A random selection of employees will be pat-frisked upon entering and exiting the prison. 141 ● Random use of canines to detect contraband will be considered. ● Security staff will be retrained in these procedures. ● Clinton management will implement effective monitoring to ensure compliance with front gate security requirements. ● During shift changes, a lieutenant or high-ranking security officer will monitor front gate searches. Correction officials from other states consulted by the Inspector General strongly endorsed these recommendations. Indeed, one official stated that all employees entering correctional facilities in his state are required to pass through a metal detector. Moreover, he noted that employees are prohibited from carrying any food or beverage into a facility, as meals are provided to staff by the facility. A correction official from another state advised that prison employees in his state are required to use only transparent containers or backpacks for items carried into the facility. Night Shift Counts The Inspector General found that Honor Block officers regularly failed to conduct required rounds after the 11 p.m. count and before the 5:30 a.m. count. Sweat was confident enough that these rounds were not conducted that he left his cell nearly every night during an approximately three-month period to work on the escape route without fear of discovery. Moreover, Sweat’s and Matt’s absence from their cells was not discovered until the morning after their escape. Over the course of the approximately 85 nights that Sweat was working in the tunnels, more than 400 counts should have occurred, any one of which, if conducted properly, would have detected Sweat’s absence and instantly foiled the escape plot. The Inspector General’s investigation also revealed that officers on the night shift throughout Clinton routinely completed and signed count slips in advance of the scheduled times of the counts. This practice, constituting a falsification of records, was longstanding and known to supervisors. This misconduct was enabled by roundsmen who collected count slips they knew to be pre-filled, or fraudulent. The watch commander used count slips he knew to be fraudulent to pre-fill and sign similarly fraudulent Master Count Sheets. 142 As a result of the Inspector General’s recommendations, DOCCS has agreed to the following: ● As already required, security staff will conduct all night checks at designated times to ensure the presence of inmates in their cells. ● Officers will be retrained in all approved methods of verifying the presence of inmates in their cells on every count. ● Supervisory security staff will periodically visit housing blocks on all shifts and monitor counts as they occur to ensure compliance with policy. The results of supervisory visits will be documented. ● DOCCS is implementing installation of electronic “night watchmen” to verify and record the completion of counts. ● DOCCS is implementing the use of thermal imaging sensors to verify the presence of inmates in cells. ● Clinton has eliminated the practice of completing and collecting count slips before actual counts are conducted, and compiling Master Count Sheets from the pre-filled count slips. Officers are now required to telephonically communicate the results of counts immediately after they are conducted. In addition, the Inspector General has recommended that DOCCS and Clinton management should consider installation of cameras on housing block galleries and in officer stations. The Inspector General is continuing discussions with DOCCS regarding this recommendation. Correction officials consulted by the Inspector General noted that their states utilize cameras for monitoring purposes widely throughout their prisons, including in housing units, recreations yards, and main corridors, among others. One official described his state’s use of an electronic night watchman system that verifies an officer’s presence at various key locations in the housing block. 143 Cell Searches The Inspector General found fundamental flaws in Clinton’s program of unannounced cell searches, an essential means of controlling inmate contraband. Although a computer produced a random list of cells for search each day, security staff selected one cell that would actually be searched, thereby injecting discretion and possible bias into a process intended to be objective. Cells searches were hasty and cursory, and failed to find any contraband 96 percent of the time. Notably, a March 21, 2015 search of Matt’s cell failed to detect the 18½-inch-by-14½inch hole in the rear wall. A proper cell search would have found the breach and thwarted the escape. As a result of the Inspector General’s recommendations, DOCCS has agreed to the following: ● The procedure for selecting cells to be searched has been modified to ensure that the cells of all inmates are searched within a defined time; the time of each search is reported; searches are not done at predictable times; all scheduled searches are actually completed and properly logged; and floorplans are updated to include all cells and accurately identify other areas. ● Cell searches must be thorough and include bar-and-hammer examinations, vent and toilet inspections, and checks of the integrity of cell walls, including observations from the catwalk. ● DOCCS is promulgating new policy governing cell searches that delineates required elements of cell searches. ● Officers will be retrained in conducting proper cell searches. ● Officers must report all contraband found during a cell search. In addition, the Inspector General recommended that DOCCS and Clinton consider establishing a team of specially trained staff to conduct all cell searches. The Inspector General is continuing discussions with DOCCS regarding this recommendation. A correction official consulted by the Inspector General recommended that cell searches be conducted by a team of officers utilized exclusively for this purpose. Another official noted that his state’s system conducts a search of an entire housing block each quarter. This official also recommended that, as a means of ensuring effective cell searches, supervisors should question officers whose searches routinely fail to uncover contraband. 144 Tunnel Security and Inspections The Inspector General found that regular inspections of the tunnel system beneath the prison did not occur. An intended quarterly tunnel inspection program was not fully implemented. Clinton’s tunnels are not currently equipped with monitoring or detection devices. Effective inspection and monitoring of the tunnels very likely would have uncovered evidence of Sweat’s and Matt’s escape activities. As a result of the Inspector General’s recommendations, DOCCS has agreed to the following: ● Clinton is implementing policy ensuring comprehensive inspections of all subterranean areas of the prison on at least a monthly basis by specially trained staff not assigned to Clinton. More frequent inspections will be conducted of key locations such as the outer wall and areas directly beneath catwalks. In addition, the Inspector General has recommended that DOCCS and Clinton study the feasibility of installing cameras, sensors, or other detection devices in the tunnel system. The Inspector General is continuing discussions with DOCCS regarding this recommendation. Catwalks The Inspector General determined that officers rarely, if ever, inspected catwalk areas of housing blocks. Sweat accessed the catwalk behind his cell almost every night over nearly three months to enter the tunnels. Palmer had allowed Sweat on the catwalk on several occasions to make unauthorized modifications to cell electrical systems. Catwalk inspections, if conducted, might have revealed evidence of the escape plan. As a result of the Inspector General’s recommendations, DOCCS has agreed to the following: ● DOCCS is instituting regular thorough inspections of, among other areas, catwalks, floors, ceilings, and manholes. ● Inmates will be prohibited from access to catwalks except for authorized purposes and with proper supervision. ● Cell electrical systems will be periodically inspected to ensure no tampering has occurred. 145 In addition, the Inspector General has recommended that DOCCS consider installation of electronic monitoring devices in catwalks. The Inspector General is continuing discussions with DOCCS regarding this recommendation. Metal Detectors Clinton operates six metal detectors at various locations to prevent inmates from transporting contraband in the prison. The Inspector General found that gaps exist in the utilization of these devices. For example, most movements of inmates to and from Industry occur without passing through a metal detector. Inmates in the company of escort officers also bypass the metal detectors. Such a situation occurred in February 2015, when Matt, in the company of an escort officer, smuggled six hacksaw blades taped to his body from the tailor shop to his cell, by-passing the metal detector on his route. As a result of the Inspector General’s recommendations, DOCCS has agreed to the following: ● DOCCS is implementing use of highly-sensitive portable metal detectors. In addition, the Inspector General has recommended that DOCCS require all inmates to pass through a metal detector whenever going to and from work, housing, and program areas, with no exception for inmates under escort; require all inmates to pass through a metal detector on all medical calls, except in life-threatening emergencies; and install cameras to monitor metal detector use. The Inspector General is continuing discussions with DOCCS regarding this recommendation. Contractor Training and Tool Control The Inspector General’s investigation found that tools and other items, including a sledge hammer and extension cord/work light, were left unsecured in the tunnels, in violation of policy, and utilized by Sweat in the escape. Additionally, a contractor failed to make a required report of a missing steel punch that Sweat had taken from a “gang box” and never returned. The contractor had also inappropriately stored spare grinder disks in the box. As a result of the Inspector General’s recommendations, DOCCS has agreed to the following: 146 ● DOCCS and the New York State Office of General Services will educate contractors on DOCCS security directives and require their attestation to comply. ● DOCCS and its contractors must ensure that all tools are accounted for daily and are properly secured in designated areas. ● DOCCS will reinforce with contractors the requirement that all missing tools must be reported immediately. ● DOCCS has implemented increased measures to enhance the security and accountability of hazardous tools, including tools with grinders, blades, and cutting disks. Tailor Shops The Inspector General found systemic deficiencies in Clinton’s tailor shops, including Joyce Mitchell’s abetting of Matt’s and Sweat’s escape, complacent and inattentive oversight by Allan Trombley and other correction officers, and a failure by Industry management to effectively address Joyce Mitchell’s misbehavior at its inception. This failure enabled Mitchell’s grossly inappropriate relationships with Matt and Sweat to develop, culminating in disastrous consequences. As a result of the Inspector General’s recommendations, DOCCS has agreed to the following: ● Clinton security and civilian management must strengthen and uniformly enforce rules governing proper inmate conduct and interaction between employees and inmates. More frequent training on these policies must be conducted. ● DOCCS is implementing policy to ensure that the custody and security of inmates takes priority over Corcraft production goals, which are secondary. ● DOCCS is implementing policy to ensure that placement and assignment of civilian staff is regularly evaluated. ● DOCCS is implementing a policy to review inmate work assignments at least annually by the Program Committee and executive management. 147 ● DOCCS is implementing policy to conduct random inspections of inmate work stations, including storage areas. ● All inmate movement will be properly documented in tailor shop logs. ● Staff will ensure that inmate time cards are accurate, and that inmates only punch in and punch out their own cards. In addition, the Inspector General has recommended that cameras must be installed in Industry to monitor employee and inmate activity; that meetings of tailor shop civilians, correction officers, and the Clinton deputy superintendent for security should occur regularly to discuss security issues; and that DOCCS and Clinton should require that Industry employees wear standard attire. The Inspector General is continuing discussions with DOCCS regarding these recommendations. Honor and General Housing Prior to the June 5 escape, Clinton operated an Honor Block as an incentive and reward for good behavior by inmates. Inmates were eligible for honor housing irrespective of their criminal backgrounds, including a history of escape, and length of sentence. Sweat was serving a life sentence without the possibility of parole; Matt was serving a term of 25 years to life and had previously escaped from a county jail. According to Sweat, his and Matt’s housing in the Honor Block assisted their escape to the extent that noise from other inmates engaged in extended recreation time, an Honor Block benefit, masked the sound of their sawing. As a result of the Inspector General’s recommendations, DOCCS has agreed to the following: ● DOCCS is implementing policy to address Honor Block, or “Earned Housing Units” eligibility, assignment and removal. The policy will exclude inmates with histories of escape or attempted escape and require greater scrutiny of inmates serving life sentences. ● DOCCS will review inmate housing assignments and reassign inmates to other housing after a defined period. ● All requests for changes in inmate housing assignments will be reviewed for appropriateness by supervisory staff. 148 Internal Controls The Inspector General found that both DOCCS central office and Clinton management have in place a variety of monitoring reports and audits assessing a broad range of operations in the prison. While several of these tools serve their intended purpose, many of them rely on assessment methods that are so cursory and superficial as to be virtually without value. Significantly, none of the reports or audits identified any of the fundamental security failures that contributed to the June 5 escape. In addition, a security alert from the DOCCS deputy commissioner of correctional facilities, issued just weeks before the escape, was not implemented by Clinton management, and no follow-up by DOCCS central office occurred. The Inspector General further found that DOCCS central office failed to ensure that security lapses that contributed to an escape from Elmira Correctional Facility in 2003 were not present in other prisons. An investigation by the DOCCS OSI in February 2015 into rumors of an improper relationship between Mitchell and Sweat was flawed and insufficient. The Inspector General has recommended that DOCCS devise and implement a program of unannounced security assessments of all facilities, on at least an annual basis, with particular focus placed on key security systems such as those that failed in this instance, and the implementation of corrective action plans with necessary follow-up. The Inspector General also recommends that DOCCS undertake a comprehensive evaluation of its internal control assessment program, which in its current form is superficial and perfunctory, and that a substantive internal control program be implemented. The Inspector General is continuing discussions with DOCCS regarding these recommendations. Security and Civilian Staff Training The Inspector General found deficiencies in DOCCS training of security and civilian staff. Although newly promoted sergeants, lieutenants, and captains are required to complete academy training, records reveal many promoted officers do not do so until well after assuming their new duties. In addition, the investigation identified a number of areas where academy and on-the-job training of officers is inadequate. For example, officers testified that they were not properly trained to check for cell wall integrity and were not aware of all the means at their disposal to ensure that a living inmate was in his cell during night rounds. 149 Weaknesses were also found in the training of civilian employees. While new civilian employees are required to complete critically important training that includes how to identify and resist inmate manipulation, they may do so at any time within the first year of their employment, not necessarily before actually beginning work in prisons. As a result of the Inspector General’s recommendations, DOCCS has agreed to the following: ● DOCCS will improve the timeliness of training for newly promoted sergeants, lieutenants, and captains. ● Both academy and on-the-job training in critical security functions such as cell searches and night rounds must be strengthened. ● New civilian employees should be required to complete appropriate academy-based training prior to assuming their duties, including training focused on dealing with inmates, and provide annual training thereafter. In addition, during the course of this investigation, the Inspector General has implemented training at every incoming DOCCS academy class on their obligations under Executive Law to report misconduct, as well as training on ethics and code of conduct. This training will also be provided for newly promoted officers and civilian employees. Discipline and Counseling The Inspector General identified a number of employees who committed criminal acts and violated DOCCS directives and policies. DOCCS has taken and will continue to pursue affirmative steps to appropriately discipline employees implicated in the Inspector General’s investigation. Many of these employees have resigned or have been terminated. Additionally, DOCCS has been cooperating with the American Correctional Association, which is assessing New York State’s prison operations to ensure compliance with national standards. The Inspector General is providing the results of this investigation to the Association to assist with its endeavors. The Inspector General has referred these matters to the Clinton County District Attorney’s Office, the New York State Joint Commission on Public Ethics, and DOCCS. 150