TDCJ Serious Incident Report and CGL Escaped Inmate Report

Texas Department of Criminal Justice
Executive Summary
Serious Incident Review – Escape
On May 24, 2022, a Serious Incident Review (SIR) team was formed at the request of the Texas Department of Criminal Justice
(TDCJ) executive leadership based on a recent incident involving an inmate escape from Inmate Transportation Central Region
Transportation (CRT) bus #153095, on State Highway 7 (SH7) west approximately two miles outside of Centerville, Texas.
The team convened on May 31, 2022, at the Alfred D. Hughes Unit in Gatesville, Texas and included Chairperson Cody Ginsel,
Division Director, Facilities Division; Marvin Dunbar, Division Director, Administrative Review and Risk Management;
Leonard Echessa, Deputy Division Director, Administrative Review and Risk Management Division; William Stephens,
Director, Security Operations, Correctional Institutions Division; Daniel Dickerson, Senior Warden, Allan B. Polunsky Unit,
Correctional Institutions Division; Dennis Crowley, Senior Warden, Huntsville Unit, Correctional Institutions Division; Tara
Burson, Deputy Director of Operations, Private Facility Contract Monitoring / Oversight Division; Cliff Pegoda, Deputy
Director, Manufacturing, Agribusiness and Logistics Division; Richard Bledsoe, Lieutenant of Correctional Officers, Region I
Security Threat Group Management Office, Correctional Institutions Division; Dale Dorman, Registered Nurse, Health
Services Division; and Lincoln Clark, Program Supervisor V, Facilities Division.
Scope:
➢ Review security protocols and processes at the Hughes Unit prior to the transport;
➢ Review security protocols and processes of Inmate Transportation during the transport;
➢ Review the initial staff response to the incident;
➢ Interview staff and inmates involved in, or with knowledge of the incident;
➢ Review supporting documentation, policy, procedures, and video surveillance;
➢ Identify measures that may prevent similar incidents from occurring; and
➢ Offer recommendations to the Executive Director for corrective action.
Inmate Information:
Inmate Lopez, Gonzalo Artemio (TDCJ #01349716), (Escapee) (Deceased) was a 46-year-old Hispanic male, S4/1A inmate.
He had served 17 years, and 16 days of a life sentence for Capital Murder from Hidalgo County and a consecutive life sentence
for Attempted Capital Murder from Webb County. He was received by the TDCJ on February 23, 2006, serving his second
incarceration. Previous convictions include a discharged 15-year sentence for Aggravated Kidnapping from Hidalgo County,
an eight-year sentence for three counts of Aggravated Assault, and a five-year sentence for one count each of Unauthorized
Use of a Motor Vehicle, Failure to Stop and Render Aid, and Possession of Marijuana. Inmate Lopez had an initial parole
eligibility date of April 26, 2045, and no minimum or maximum expiration date. During his incarceration, he received 28
disciplinary cases, including six major cases and 22 minor cases. Inmate Lopez was confirmed as an ex-member of the Mexican
Mafia however he completed the Gang Renunciation and Disassociation process on August 4, 2014. Classification records
reveal a Security Precaution Designator (SPD) Escape Attempt/Other Escapes (EA/EX) from Hidalgo County Jail, March 27,
2006. Two Inmate Protection Investigations were filed during his incarceration.
Staff Information
Correctional Officer V Randy Smith, CRT (Driver), is a 54-year-old White male with a hire date of May 21, 2009. He was
assigned to Inmate Transportation on November 1, 2014. Officer Smith was issued a handgun loaded with ammunition that
was secured in a holster fastened to his duty belt. His last firearms requalification date was December 13, 2021. During the
event, Officer Smith sustained a puncture wound to his left palm and right hand. He was evaluated and treated by local
Emergency Medical Services (EMS). Upon arriving at his residence on May 12, 2022, a puncture wound to his upper torso was
discovered at which time he proceeded to obtain a medical evaluation and treatment.
Correctional Officer V Jimmie Brinegar, CRT (Rear Compartment Second Officer), is a 62-year-old White male with a hire
date of June 21, 2007. He was assigned to Inmate Transportation on August 01, 2017. Officer Brinegar was issued a handgun
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Executive Summary
loaded with ammunition that was secured in a holster fastened to his duty belt. In addition, Officer Brinegar was equipped with
a shotgun loaded with ammunition. His last firearms requalification date was September 16, 2021.
Incident Synopsis:
On Thursday, May 12, 2022, Officer Smith, and Officer Brinegar were assigned to the Robertson CRT bus #153095 (RB2)
transport route. At approximately 0500 hours, RB2 transport picked up 15 general population and one restrictive housing inmate
from the Byrd Unit in Huntsville, Texas. They departed at approximately 0530 hours, enroute to the Hughes Unit, arriving at
approximately 0840 hours.
Upon arrival, a relay exchange of inmates took place between RB2 and transport buses from Huntsville and Abilene. Inmates
were off loaded for unit assignment at the Hughes Unit. Officer Smith began the process of preparing the general population
inmates assigned for the RB2 transport, who were located in the 12-building breezeway holding area, while Officer Brinegar
began the process of preparing the restrictive housing inmates assigned to 12-building. At 1018 hours, Officer Brinegar
proceeded to 12-building A/B legal booth where he performed a strip search of inmate Lopez. Upon completion, he applied all
transport restraints (hand, black box with lock, restraint chain and leg). Inmate Lopez was then escorted to the 12-building sally
port. His identification was verified, and he was given a sack meal. His carry-on property was placed inside his chain bag,
which was secured underneath the bus. He was then escorted to the bus and placed in the restrictive housing compartment. The
relay and transfer of inmates was completed at approximately 1111 hours. RB2 departed the Hughes Unit for a return trip to
the Huntsville area units with nine general population and seven restrictive housing inmates.
At approximately 1315 hours, RB2 was traveling on SH7 east en route to the Estelle Unit. Four to six miles outside of
Centerville, Officer Smith felt a tug on his handgun holster while driving. He looked down and witnessed inmate Lopez coming
through the bottom of the restrictive housing compartment door, attempting to gain possession of his handgun. Officer Smith
immediately covered his handgun with his right hand and attempted to stop the bus. Once the bus slowed to approximately 30
miles per hour (mph), Officer Smith engaged the air brake handle to lock the brakes and the bus came to an abrupt stop,
thrusting inmate Lopez further into the driver’s compartment of the bus. Officer Smith kicked inmate Lopez to the stairwell of
the bus; however, inmate Lopez did not release his hold on the handgun, and Officer Smith fell forward to the stairwell of the
bus with the inmate. During the fall, Officer Smith’s elbow inadvertently struck the door release handle, causing both to tumble
out of the bus onto the pavement of SH7. Inmate Lopez proceeded to gain possession of the handgun by stabbing Officer Smith
with an eight-to-ten-inch metal weapon, then inmate Lopez pressed the quick disconnect on the holster and released the handgun
from Officer Smith’s duty belt.
Officer Brinegar exited the back of the bus with the shotgun, under the assumption the bus had been involved in an accident.
Once he rounded the rear right side of the bus, he observed Officer Smith engaged in a ground altercation with inmate Lopez.
Officer Brinegar yelled for inmate Lopez to get off Officer Smith, at which time inmate Lopez jumped up and reentered the
bus. Officer Brinegar proceeded to the front of the bus, helping Officer Smith to his feet. Officer Smith took possession of the
shotgun from Officer Brinegar. Officer Smith informed Officer Brinegar inmate Lopez was attempting to escape and had gained
possession of his handgun. Officer Brinegar drew his handgun and yelled at inmate Lopez, who was in the driver’s seat, to stop
or he would shoot. Inmate Lopez placed the bus in forward gear and Officer Brinegar discharged his handgun two times in an
attempt to stop him. With Officer Smith’s handgun in hand, inmate Lopez pointed the holstered handgun towards Officer
Brinegar, resulting in him stepping out of the direct line of fire. Officer Brinegar then discharged two additional rounds through
the right passenger compartment window to strike and stop inmate Lopez. As inmate Lopez continued to drive away from the
scene, Officer Smith discharged one round from the shotgun, striking the right rear outside tire of the bus, causing it to go flat.
Inmate Lopez then continued to drive east on SH7 towards Centerville.
Chief of Police for the City of Jewett Police Department, Sean O’Reilly, arrived on the scene moments after the incident. He
drove up to Officer Smith and inquired about the situation. Officer Smith informed Chief O’Reilly an inmate had obtained his
handgun and was escaping on the bus. Chief O’Reilly pursued RB2; however, he did not transport either officer with him.
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Executive Summary
Officer Smith and Officer Brinegar followed on foot in the direction of the bus. An unidentified civilian in a pickup truck
traveling west bound from the opposite direction stopped and asked Officer Smith if they were with the bus that had just
wrecked towards Centerville. The civilian then provided a ride to Officer Smith to that location. Upon arriving, Officer Smith
observed law enforcement officers already on-scene. Officer Smith was notified inmate Lopez was on foot in the woods and
law enforcement was in pursuit. Officer Smith retrieved the TDCJ cellular phone from the back of the bus and notified
Lieutenant Patrick Daniel, CRT, of the escape. Officer Brinegar, who obtained a ride to the scene by an unidentified civilian
18-wheeler driver, arrived shortly after. Upon inspection of the bus, the handgun taken from Officer Smith by inmate Lopez
was located inside the driver compartment, still in the holster. Activation of the TDCJ Escape Plan was initiated.
Local law enforcement established an initial perimeter. At approximately 1322 hours, upon notification of incident, Assistant
Warden Shawn Pinney and Captain Charlton Greene, Inmate Transportation Headquarters (ITH), responded to the scene.
Notifications were made to the Boyd Unit at 1331 hours, Ferguson Unit at 1334 hours, and Northern Region Transportation at
1335 hours for assistance. Staff were deployed immediately to SH7 west in Centerville. Manufacturing, Agribusiness and
Logistics (MAL) Division Director Billy Hirsch arrived on scene at 1415 hours and took over as Incident Commander.
Deployment of additional staff resources began as they arrived on scene along SH7.
CRT arrived with additional staff and rescue bus #153107 at 1450 hours. At 1537 hours, all 15 remaining inmates, nine general
population and six restrictive housing, were loaded onto rescue bus #153107 and departed for the Huntsville Unit, arriving at
1620 hours. Upon arrival, all inmates were evaluated by unit medical staff with no injuries reported.
Upon notification of the incident, at approximately 1345 hours, Correctional Institutions Division (CID) Deputy Director John
Werner established a 24-hour command center in Huntsville, Texas. This command center provided logistical and intelligence
support to Director Hirsch in the field from the Brad Livingston Administrative Headquarters.
Pack and scent specific canine response teams were deployed to the area of the escape, and perimeter containment zones were
established on SH7, County Road (CR) 318, CR 317, CR 320, and Interstate 45 service road. The perimeter was maintained
24-hours per day with an average of more than 350 staff assigned on a rotating schedule.
At approximately 1445 hours, a pair of socks were collected from Lopez’s personal property stored on the bus and utilized as
a scent article. The Boyd Unit pack canines were the first pack canines to arrive on scene and were deployed at the bus wreck
location at 1450 hours. The pack canines picked up the track of inmate Lopez heading in a northeastern direction. A brief time
later, inmate Lopez was sighted running in a dry creek bottom northeast of the wreckage site. The canine track was lost east of
that location. The Beto Unit pack canines were deployed to search an area where Boyd Unit’s pack canines had lost track but
had negative results. The Estelle Unit scent specific canines were then deployed at the sight location and pursued north to
northeast before losing the track in a dense brushy area. Inmate Lopez’s scent was not picked up again. Throughout the
remainder of the search, pack, scent specific, and cadaver canines were utilized inside and outside the perimeter with negative
results.
Building structures located inside the search perimeter were cleared by law enforcement during the search period. On May 15,
2022, a search team consisting of law enforcement and TDCJ officers conducted grid searches of the inside perimeter on both
horseback and foot. The search continued with surge teams on May 16-17, 2022, with negative results. On May 18, 2022,
suspicious calls continued. Canines were utilized to continue searching, while the inside perimeter was allowed to settle for
scent purposes. On May 19-20, 2022, 12 pack canine teams were deployed inside the perimeter as a grid from south to north
with negative results.
On May 31, 2022, law enforcement received information concerning a burglary of a previously cleared cabin within the search
perimeter. Deoxyribonucleic Acid (DNA) and fingerprints were collected on June 1, 2022, by law enforcement officers. On
June 2, 2022, at approximately 1610 hours, a positive match to inmate Lopez was returned.
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Executive Summary
On June 2, 2022, law enforcement officers also received a call from an individual who had become concerned after not hearing
from a relative in the area. Law enforcement officers responded to the residence and discovered the deceased bodies of five
individuals, later identified as two adult males and three minor children. A 1999 white Chevrolet Silverado pickup, license
plate DPV4520, was missing from the residence. It was believed inmate Lopez committed the murders and fled in the vehicle.
A “Be on the Lookout” (BOLO) was issued for law enforcement agencies statewide.
Shortly after 2200 hours, on June 2, 2022, Atascosa County law enforcement officers located and followed the stolen vehicle
traveling on SH16 in Jourdanton, Texas until positive identification was made. The vehicle was disabled with spike strips, and
the exchange of gunfire broke out between inmate Lopez and Atascosa County deputies. At 2230 hours, the TDCJ received
information that inmate Lopez had been shot and was deceased. No law enforcement was injured during the exchange of
gunfire.
Throughout this incident, TDCJ coordinated and collaborated with many law enforcement agencies to include the Leon County
Sheriff’s Department, Centerville Police Department, Jewett Police Department, Texas Department of Public Safety, Texas
Rangers, Federal Bureau of Investigation, United States Marshall Service, Drug Enforcement Agency, and Office of the
Inspector General (OIG). Deactivation of the Centralized Command Center was conducted at 1730 hours on June 3, 2022, day
23 of the incident. The Texas Rangers and the OIG are continuing their investigation into the incident.
Investigation Summary:
Hughes Unit
Hughes Unit staffing on May 12, 2022, was at 57%. The unit was allocated 556 officers with 318 filled positions. Staffing
available for operations on May 12, 2022, was 34 general population and 19 restrictive housing positions. Twenty-one general
population and 12 restrictive housing priority one positions were not staffed. CID Region VI Director Garth Parker was advised
and approved of staffing for this date.
Inmate Lopez was assigned to the Hughes Unit on September 2, 2016 and was appropriately assigned as a 1A custody inmate
based on his incarceration history. A classification review was conducted on inmate Lopez using the Current Institutional
Adjustment Record screen. Incomplete and inaccurate information was found. Two data entries on the screen were documented
incorrectly. The EX SPD stating inmate Lopez walked away from Hidalgo County Jail should have been an EZ, the precaution
designator for escapes more than 10 years old in accordance with Administrative Directive (AD) 04.11, Security Precaution
Designators. The EA designator had an incorrect date of occurrence. The inmate photo on the Classification Profile was dated
March 18, 2016. All inmates should have an updated photo every three years per Unit Classification Procedures (UCP) 6.01,
“Updating Offender Photographs.” There were two State Classification Committee hearings not documented on the computer
or documented incorrectly as per UCP 1.01, “Unit Classification Committee (UCC) Composition and Proceedings.” The
hearing on May 19, 2020 was not documented. The hearing on May 4, 2021 was not added to the computer until June 18, 2021.
A review of inmate Lopez’s history of transports for medical appointments revealed three transports to the Byrd Unit, seven to
the Estelle Unit, and five to Hospital Galveston since March 5, 2021. Inmate Lopez was being transported to the Estelle Unit
for a scheduled medical appointment on May 13, 2022.
According to information obtained through the Mail System Coordinators Panel, six books at the Hughes Unit were denied for
inmate Lopez. The books listed are Mind Control, Truth Detector, The Ninja Mind, Ultimate Survival Manual, Unlocking
Secrets, and the U.S. Army Survival Manual. Each book contained either manipulation techniques, offensive and defensive
fighting techniques, or the manufacture of weapons. There currently is no required mechanism in place for unit administration
notification when denials of this nature are made.
A comprehensive review of the video surveillance footage at the Hughes Unit, prior to transport activities, revealed that on
May 12, 2022, at 0048 hours, Correctional Officer IV Randall Smith issued inmate Lopez two red chain bags to pack his
personal property in preparation of the outgoing chain that morning. At 0126 hours, Officer Smith was observed returning to
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Executive Summary
the cell and the door was opened by Correctional Officer IV Bernard Guishard, who was assigned as the 12F Housing Picket
Officer. Officer Smith failed to conduct a proper strip search or place hand restraints on inmate Lopez prior to opening the
inmate’s cell door. Officer Smith was observed retrieving one bag of property from inmate Lopez without searching the
property to determine the contents of the bag and placing it in front of a neighboring cell. Officer Smith then proceeded back
to Lopez’s cell, where he removed the remaining bags of inmate Lopez’s property and transported them to the 12F Housing
Picket for inventory by Officer Guishard. Inmate Lopez’s door remained unsecured with him unrestrained during this process.
The investigation revealed inmates were documenting what items they had in a bag on a piece of paper and Officer Guishard
was using their notations as inventory instead of conducting a property inventory as outlined by policy. At 0204 hours, Sergeant
Joshua Watson was observed making security rounds. When Sergeant Watson approached the neighboring cell, he opened the
food tray slot and handed the contents of inmate Lopez’s property, that was previously placed in front of the neighboring cell,
to him without searching the contents or checking for ownership.
A review of the May 11, 2022 Second Shift Restrictive Housing roster along with staff interviews revealed 12-building A-F
pods were assigned three rovers out of the total seven required: Officer Smith, Sergeant Watson, and Sergeant Kristopher
Sharp. However, Sergeant Watson and Sergeant Sharp were conducting cell moves and rounds outside the assigned pods from
the shift roster, leaving Officer Smith to conduct rounds in all 36 sections. In addition, a review of the Daily Activity Log (I-
216) revealed rounds were documented at 30-minute intervals, but not all rounds were physically conducted. Cell inspections
were notated as being completed when they were not.
At 0934 hours, Correctional Officer IV Gerardo Velasquez was observed approaching the cell of inmate Lopez with
Correctional Officer II Dillion Miller, On the Job Training (OJT), and then opening the food tray slot in preparation to conduct
a strip search of inmate Lopez. Video surveillance reveals Officer Velasquez failed to conduct a proper strip search of inmate
Lopez by not instructing inmate Lopez to complete the required steps and not maintaining direct line of sight following the
search. At 0941 hours, hand restraints were applied to inmate Lopez, he was removed from the cell in full clothing and footwear,
and inmate Lopez then dropped his mattress and blanket off in front of a neighboring cell. OJT Officer Miller retrieved a brown
paper sack from the cell and assisted with escorting inmate Lopez to 12-building A/B legal booth. The content of the paper bag
was later identified as a radio.
At approximately 1018 hours, CRT Officer Brinegar and OJT Officer Miller proceeded to 12-building A/B legal booth. Video
surveillance revealed CRT Officer Brinegar failed to conduct a proper strip search of inmate Lopez by not instructing Lopez
to complete the required steps and not maintaining direct line of sight following the search. The booth also did not provide for
clear and direct sight of inmate Lopez during the search due to a partially solid door. Upon completion of the search, CRT
Officer Brinegar applied all transport restraints (hand, black box with lock, restraint chain, and leg). However, the application
of the leg restraints was improper as the restraints were placed over inmate Lopez’s pants leg. Therefore, the restraints fit
loosely around inmate Lopez’s legs. CRT Officer Brinegar double locked the hand restraints. Inmate Lopez was also observed
in two-piece white clothing and personal boots (commissary purchased) versus a traditional TDCJ white jumper and slide type
shoes used to transport restrictive housing inmates. CRT Officer Brinegar and OJT Officer Miller escorted inmate Lopez
through the exit of 12-building and did not utilize the Body Orifice Security Scanner (BOSS) chair. Inmate Lopez was then
escorted to the 12-building sally port, identified, and provided a sack meal for transport, while his carry-on personal property
was secured in his chain bag underneath the bus. He was escorted to the bus and placed in the restrictive housing compartment.
CRT Officer Brinegar returned to 12-building to retrieve additional restrictive housing inmates assigned to the transport,
leaving CRT Officer Smith with the bus. When this is reviewed on the surveillance system, CRT Officer Smith is observed
leaving the bus unattended for approximately 30 minutes. Surveillance footage also revealed that additional inmates loaded
onto the bus at the Hughes Unit on May 12, 2022 were not properly searched or examined for restraint placement by a
supervisor. The parcel scanner was discovered as inoperable during the team’s visit and had been down since April 2022, due
awaiting a technician to fix a software issue. Therefore, no property was scanned prior to loading it onto the bus. After relay
and transfer of inmates was completed at approximately 1111 hours, the RB2 bus departed en route to Huntsville area units
with nine general population and seven restrictive housing inmates.
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Executive Summary
The review of video surveillance footage at the Hughes Unit and the Employee/Visitor Log signature book did not support
weekly administrative rounds by the Major or Captain assigned to 12-building.
All staff interviewed accepted responsibility for improper searches, application of restraints, trafficking of inmate property,
failure to utilize contraband detection equipment, and failure to make supervisory rounds.
Inmate Transportation
Interviews conducted with inmates on the RB2 transport indicated that upon inmate Lopez boarding the bus and Officer Smith
stepping away, inmate Lopez asked them if they were, “ready to rock and roll,” or something similar in nature, and made the
comment it was their “lucky day.” Upon leaving the 12-building sally port and departing the back gate, witness inmates
indicated that inmate Lopez presented two eight-to-ten-inch metal weapons with nylon string attached and what resembled a
handcuff key in his mouth. Witnesses stated inmate Lopez asked how long the inmates in the restrictive housing compartment
sentences were to determine, if any, wanted to escape with him. One inmate initially indicated he wanted to go but changed his
mind when he realized inmate Lopez planned to kill Officer Smith and Officer Brinegar, drive the bus to Interstate 45, hijack
a car, murder the occupant, and drive to San Antonio to hold up until the search scaled down. He stalled by telling Lopez he
could not get out of his restraints and stated he was not ready for the “needle,” meaning execution, if caught. Once departed
from the unit, witnesses described the noise in the restrictive housing compartment as increasing while en route. Three inmates
were instigating loud rapping noises, banging, and blocking the view of Officer Brinegar who was holding security at the back
of the bus. Witnesses indicate it did not take inmate Lopez long to remove the restraints, as the black box did not cover the
hand restraint keyhole. This was confirmed by reviewing the restraints secured in evidence at the OIG Huntsville headquarters.
The hand restraint model utilized with a black box did not completely cover the keyhole, allowing access to open and tamper
with the equipment. Once the restraints were removed, witnesses indicated it took inmate Lopez approximately one hour and
30 minutes to break the expanded metal welds free on the bottom of restrictive housing compartment entrance door utilizing
the two metal weapons. None of the inmates assigned to the transport alerted either Officer Smith or Officer Brinegar of inmate
Lopez’s actions on the bus prior to initiating the assault on Officer Smith and escaping.
Additional interviews with inmates revealed they take advantage of not being properly searched and state they are often told in
advance by medical staff of their upcoming scheduled off unit medical appointments, providing them improper knowledge of
when they will be transported.
During an interview with Officer Brinegar, he stated both he and Officer Smith conducted a pre-trip inspection of the bus prior
to departure on the morning of May 12, 2022, which consisted of vehicle operation checks such as damage, locks, integrity of
the expanded metal, and bars. He felt he had done a proper strip search and had placed the leg restraints higher over inmate
Lopez’s pant legs because he was wearing higher ankle boots. At or near the four-way stop in Marquez, Texas, he could tell
the inmates in the restrictive housing compartment were becoming increasingly louder, at which time he contacted Officer
Smith via the bus phone system to ensure he was okay. A short while later when Officer Smith hit the air brake and the bus
came to an abrupt stop, Officer Brinegar believed the bus had been involved in an accident, so he exited the back of the bus.
He proceeded towards the back right side to the front of the bus and was shocked to see an inmate on top of Officer Smith
stabbing him in the middle of SH7. Officer Brinegar stated he yelled for inmate Lopez to get off Officer Smith. He did not fire
at inmate Lopez immediately, fearing he would strike Officer Smith. Once inmate Lopez saw Officer Brinegar, he moved
towards the entrance of the bus. Officer Brinegar proceeded to Officer Smith’s location and assisted him to his feet. Officer
Smith took possession of the shotgun as he told Officer Brinegar that inmate Lopez had his handgun, was attempting to escape
in the bus, and to shoot him. Officer Brinegar then fired two rounds toward the stairwell at inmate Lopez on the bus. Inmate
Lopez pointed the holstered handgun at him, not noticing the handgun was still holstered, and Officer Brinegar immediately
stepped out of direct fire. Officer Brinegar fired two more rounds into the driver’s compartment through the passenger side
window, directly at inmate Lopez as he drove away. No additional shots were fired from Officer Brinegar, as he stated he felt
the angle of the shots would potentially endanger the lives of the inmates in the restrictive housing compartment. Officer Smith
fired one round from the shotgun, blowing out the back right tire.
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Executive Summary
During an interview with Officer Smith, he confirmed he and Officer Brinegar conducted a pre-trip inspection and he personally
checked all doors, locks, and integrity of expanded metal and bars. The vehicle proceeded to the Byrd Unit for pick-up of
outgoing chain and departed for the Hughes Unit. Upon arriving at the sally port of the Hughes Unit, Officer Smith states they
pulled in and made relay exchanges with other transport buses on scene. He then pulled RB2 out of the sally port to allow for
relay exchange of inmates between the other transports. Once completed, RB2 re-entered the sally port, and Officer Brinegar
proceeded to 12-building to retrieve restrictive housing inmates for the return to Huntsville units, while he began the process
of identifying the general population inmates scheduled for the transport. Officer Smith stated he knew the return trip was going
to be loud due to the number of restrictive housing inmates assigned on the transport. Once the vehicle departed from the
Hughes Unit, the inmates in the restrictive housing compartment became increasingly louder while en route, as they were
beating, banging, rapping, and stomping. At or near Marquez, Texas, Officer Brinegar called him on the bus phone system and
asked if he was okay, to which he replied he was, and they discussed how loud it was in the restrictive housing compartment.
He remembers stopping at the stop sign in Robbins and, after accelerating back up to approximately 60 mph, he felt a tug on
his handgun located on the right-hand side of his duty belt. He looked down and observed inmate Lopez lying on his back
tugging on his holstered handgun. Officer Smith began slowing down, attempting to maintain control of both the vehicle and
his handgun. Once the bus speed reduced to approximately 30 mph, he engaged the air brake, bringing the bus to an abrupt
stop within 100 to 150 ft. slide. Inmate Lopez slid forward into the dash when the air brake was engaged but did not let go of
Officer Smith’s holstered handgun. Officer Smith released the seatbelt harness and attempted to kick inmate Lopez several
times trying to break his grip, but it resulted in both of them falling into the stairwell. While falling, he felt his elbow strike the
door release, and they both fell out onto the pavement of SH7. Inmate Lopez landed on top of Officer Smith and stabbed him
with, what he described as, an eight-to-ten-inch metal object with a circumference comparable in size of a pencil. Officer Smith
heard Officer Brinegar yelling but could not discern what was said. Inmate Lopez jumped up and ran back onto the bus with
Officer Smith’s handgun still holstered. Inmate Lopez had managed to obtain Officer Smith’s handgun from the quick release
attachment worn on his duty belt. Officer Brinegar assisted him to his feet, and he told Officer Brinegar inmate Lopez had his
handgun, was escaping, and to shoot him. Officer Smith then obtained the shotgun from Officer Brinegar, chambered a round,
and Officer Brinegar was yelling for the inmate to stop. Officer Brinegar then fired multiple shots towards inmate Lopez as the
bus began driving away. Officer Smith stated he then fired one round from the shotgun into the rear right tire of the bus, blowing
it out. As the bus began heading east on SH7, he heard a siren approaching, which he identified as a law enforcement officer
from Jewett Police Department. He informed the officer an inmate had just escaped in the bus and had his handgun. He stated
the Jewett officer then drove off in the direction of the bus without transporting either Officer Brinegar or himself. Officer
Smith then proceeded in the direction of the bus on foot, and an unidentified civilian driver in a pickup heading west on SH7
stopped and asked if he was with the bus that wrecked a short way down the road. The driver then provided him a ride to the
bus location. Upon arriving, law enforcement officers were already on the scene and surrounding the bus. He asked law
enforcement officers where the inmate was that had been driving the bus, and was told he took off running across the field and
officers were in pursuit of him. Officer Smith then retrieved the cell phone from the rear of the bus and called Lieutenant Daniel
at ITH to advise him of what had occurred. He stated Officer Brinegar and other TDCJ staff arrived, and he was hyperventilating
with no energy and needed to catch his breath. A unit sergeant on scene told him to sit down in the van and cool off. He was
later directed to the ambulance that had arrived to be evaluated. Sergeant Kelvin Leigh, CRT, transported him to the Byrd Unit
for evaluation before proceeding to the ITH to complete documentation of the incident. When he arrived home that evening
and removed his shirt, his spouse noticed a wound on his chest, which he did not know he had sustained. He proceeded to
obtain a medical evaluation and treatment.
During interviews with ITH administrative staff consisting of Assistant Warden Pinney, Major Everardo Gonzalez, and Captain
Brian Nye, each stated upon notification of the incident their collective immediate response was to notify the Boyd and
Ferguson Units to request assistance in responding to the bus accident in Centerville, Texas. Assistant Warden Pinney and
Captain Greene responded to the accident scene with Captain Nye initiating the Transportation Command Center. A brief time
later, Major Gonzalez arrived, and they began accounting for staff, handguns, and identities of the inmates assigned to the
transport.
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Executive Summary
Supervisory oversight by transportation staff in the field consisted of roving sergeants spot checking at various times when
available. However, when questioned when this practice last occurred, it had not been practiced recently due to staffing
shortage, as available sergeants were filling correctional officer positions on transports. In addition, ITH Administration has
not made routine field rounds throughout the state, nor is there a mechanism in place to document such rounds by either
administration or roving field sergeants.
Inmate Transportation currently maintains an inventory of approximately 3,500 restraints and was not aware of any altered
black boxes. However, upon inspection of random samples of black boxes and hand restraints, it was revealed there were
combinations that allowed the keyhole to be exposed.
Staffing for ITH, CRT was 64% on the day of the incident. CRT is allotted 117 staff members with 75 positions filled and 42
positions vacant. Four staff were assigned to Operation Lone Star, and thirteen staff were not available for assorted reasons,
bringing the operational staffing level to 49.5%. On May 12, 2022, 23 transports were scheduled with a total of 47 staff
available. There were two OJT staff available that were assigned as third security officers on a transport that day for their OJT
ride along. Nine of the 23 transports had restrictive housing inmates, and staffing did not allow for all nine to have a third
officer assigned. A requirement for Inmate Transportation staff is to have Class B Commercial Driver License (CDL) with
passenger endorsement, with a minimum of two CDL licensed per transport for relief factors.
Recent history of the 2015 Blue Bird Bus #153095, assigned to the Abilene Hub, Western Regional Transportation (WRT),
was reviewed. The bus was assigned to John M. Wynne Mechanical on April 21, 2022, placed back in service to CRT on April
29, 2022, back to WRT on May 03, 2022, returned to CRT May 09, 2022, returned to WRT May 10, 2022, and returned to
CRT on May 11, 2022.
An inspection of transport buses, to include RB2, revealed the plexiglass covering the expanded metal areas was discolored,
scratched, and difficult to see through. The dark expanded metal also makes it difficult to see into the inmate compartment.
The overhead driver’s mirror is adjusted for view into the inmate occupant sections but does not view directly at the bottom of
the restrictive housing compartment door unless manually placed in that position and you would then not be able to view into
the occupant compartment. Without the mirror, it is extremely challenging to turn around and view through the restrictive
housing compartment door as it is slanted away from the driver’s seat view. The restrictive housing compartment door base
where inmate Lopez crawled through was approximately 8 1/2” x 19” and the expanded metal was bent or pried apart with
jagged edges on the ends, consistent with inmate witness reports. The rear officer compartment seat sits low, and the view can
be obstructed by inmates in the general population compartment. Excessive truck mail in the rear officer compartment area was
also determined to be a safety and security issue. The number of bags block the placement and securing of the shotgun, fire
extinguisher, and back exit door release.
Initial Response
A review of the initial response to the escape was evaluated along with establishment of command structure. Initial response
was immediate by local law enforcement in the vicinity, and a roving law enforcement perimeter was quickly established. Due
to the centralized location being within an hour or so from TDCJ units, response from staff was swift. Initial coordination was
to identify and transfer the remaining 15 inmates to the rescue bus for transit en route to the Huntsville Unit. Director Hirsch
remained as the Incident Commander on scene and directed TDCJ staff while simultaneously coordinating with law
enforcement. Security Operations Director William Stephens began deploying TDCJ staff to positions around the initial
established perimeter. Later that evening, a centralized command location was established on private property approximately
500 yards from where the bus wrecked, located on SH7 west. Law enforcement established a command on the northern side of
the property, while TDCJ established command at the southern entrance. CID Director Bobby Lumpkin arrived at the
Centerville TDCJ command site and assisted Director Hirsch throughout the incident as relief. At times, both division directors
were together on scene and there was confusion noted by staff as to which one of the two they should report as there was no
distinguishing credentials of who was in command at the time.
Page 8 of 14
Executive Summary
Deputy Director Werner established the Central Command Center in Huntsville, at the Brad Livingston Administrative
Headquarters at 1345 hours, on May 12, 2022, and served as a support to the Incident Commander in the field. Personnel from
the Security Threat Group Management Office, Office of Emergency Management, and Information Technology Division
provided support as well in the Command Center. The review revealed an expanded incident command structure in the
command center to support the field, to include logistics and finance sections would have been beneficial.
A review of the canine deployment strategy highlighted the necessity to allow pack canines to thoroughly work the area prior
to deploying staff on foot with a scent specific canine. It is believed the right call was made to bring in the Beto Unit pack
canines when the Boyd Unit pack canines lost inmate Lopez’s track. However, when there were negative results, scent canines
were deployed, and the creation of inner perimeters led to cross contamination of odors for the pack canines. It is reasonable
to believe the Boyd Unit pack canines lost the original track by making a wrong turn, thus the Beto Unit pack canines were
potentially searching the wrong area. Pack canines should be utilized in a wooded area repeatedly with different teams before
deploying scent specific canines.
A review of environmental conditions for the search period indicated weather conditions were extremely challenging. The
conditions were hot, windy, and dusty, limiting the amount of time canines could be utilized before dehydration and overheating
set in.
Findings:
1. Correctional Officer V Jimmie Brinegar, failed to properly strip search inmate Lopez, failed to utilize the BOSS Chair
or Handheld Metal Detector during course of search, and failed in calling for supervisor to examine placement of
restraints prior to loading inmate Lopez on the bus, in violation of Post Order 07.070 (rev 9) Transport Officer and
Security Memorandum 03.05 (rev 3) Contraband Detection Equipment.
2. Correctional Officer V Randy Smith left the bus unattended for approximately 30 minutes after inmate Lopez was
loaded into the restrictive housing compartment, in violation of Post Order 07.070 (rev 9) Transport Officer.
3. Correctional Officer IV Randall Smith, failed to properly search or apply hand restraints prior to opening the cell door
of inmate Lopez, walking away from cell front, and leaving cell door unsecured. In addition, failed to search inmate
Lopez’s property, knowingly placing this un-inventoried property in front of a neighboring inmate’s cell, in violation
of Post Order 07.006 (rev 6) Administrative Segregation Officer and Administrative Directive AD 03.72 (rev 6)
Offender Property.
4. Correctional Officer IV Bernard Guishard, failed to properly inventory inmate property prior to departure of medical
chain, in violation of Administrative Directive AD 03.72 (rev 6) Offender Property.
5. Sergeant Joshua Watson, failed to search property and passed contraband to an inmate in a neighboring cell, in violation
of Administrative Directive AD 03.72 (rev 6) Offender Property.
6. Correctional Officer IV Gerardo Velasquez, failed to conduct a proper strip search of multiple inmates to include
inmate Lopez, in violation of Post Order 07.006 (rev 6) Administrative Segregation Officer.
7. Major Treyvon Hocutt, failed to document administrative rounds in inmate housing areas of 12-building, in violation
of Post Order 07.002 (rev 10) Major of Correctional Officers.
8. Captain Shane Martin, failed to document administrative rounds in inmate housing areas of 12-building, in violation
of Post Order 07.003 (rev 10) Captain of Correctional Officers.
Page 9 of 14
Executive Summary
9. Lieutenant Harvey Haws, failed to ensure supervisory inspection of restraint placement on departing restrictive housing
assigned inmates, in violation of Post Order 07.006 (rev 6) Administrative Segregation Officer.
10. Correctional Officer IV Nicholas Walton, failed to conduct a proper strip search on an inmate being transported, in
violation of Post Order 07.006 (rev 6) Administrative Segregation Officer.
11. Correctional Officer V Gerald Defreitas, failed to conduct a proper strip search of an inmate being transported in
violation of Post Order 07.006 (rev 6) Administrative Segregation Officer.
12. Correctional Officer V Aaron White, failed to conduct a proper strip search of an inmate being transported in violation
of Post Order 07.102 (rev 6) Chain Officer.
13. Correctional Officer II Brantley Stewart, failed to search property and passed contraband to an inmate in a neighboring
cell, in violation of Administrative Directive AD 03.72 (rev 6) Offender Property.
14. Sergeant Kristopher Sharp, during the investigation, was discovered to have falsified the cell search log indicating
inmate Lopez’s cell had been searched when it had not, in violation of Security Memorandum 03.02 (rev 7) Security
Searches.
15. Correctional Officer IV Michael McElhaney, during the investigation, was discovered to have falsified the cell search
log indicating inmate Lopez’s cell had been searched when it had not, in violation of Security Memorandum 03.02 (rev
7) Security Searches.
16. Correctional Officer IV Damion Lawson, during the investigation, was discovered to have failed to search property
and passed contraband to several identified cells, in violation of Administrative Directive AD 03.72 (rev 6) Offender
Property.
17. Correctional Officer IV Tanya Miller, during the investigation, was discovered to have failed in the application of
restraints on a restrictive housing inmate, failed to search property, and passed contraband to several identified cells,
in violation of Administrative Directive AD 03.72 (rev 6) Offender Property and Post Order 07.006 (rev 6)
Administrative Segregation Officer.
18. Inspections of 12-building I-216, Daily Activity Logs, revealed the documentation to be falsified concerning the
security rounds made, in violation of the Restrictive Housing Plan.
19. Inmate Lopez had an SPD indicator code of EX instead of EZ, in violation of Administrative Directive (AD) 04.11 (rev
6) Security Precaution Designators.
20. Inmate Lopez’s Classification Profile photo was older than three years, in violation of the Unit Classification
Procedures (UCP) 6.01.
Recommendations:
1. MAL leadership should review Correctional Officer V Jimmie Brinegar, for possible policy violations of Post Order
07.070 (rev 9) Transport Officer and Security Memorandum 03.05 (rev 3) Contraband Detection Equipment, to
determine if disciplinary action is warranted.
2. MAL leadership should review Correctional Officer V Randy Smith, for possible policy violation of Post Order 07.070
(rev 9) Transport Officer, to determine if disciplinary action is warranted.
Page 10 of 14
Executive Summary
3. CID leadership should review Correctional Officer IV Randall Smith, for possible policy violation of Post Order
07.006 (rev 6) Administrative Segregation Officer and AD 03.72 (rev 6) Offender Property, to determine if disciplinary
action is warranted.
4. CID leadership should review Correctional Officer IV Bernard Guishard, for possible policy violation of AD 03.72
(rev 6) Offender Property, to determine if disciplinary action is warranted.
5. CID leadership should review Sergeant Joshua Watson, for possible policy violation of AD 03.72 (rev 6) Offender
Property, to determine if disciplinary action is warranted.
6. CID leadership should review Correctional Officer IV Gerardo Velasquez, for possible policy violation of Post Order
07.006 (rev 6) Administrative Segregation Officer, to determine if disciplinary action is warranted.
7. CID leadership should review Major Treyvon Hocutt, for possible policy violation of Post Order 07.002 (rev 10) Major
of Correctional Officers, to determine if disciplinary action is warranted.
8. CID leadership should review Captain Kristopher Martin, for possible policy violation of Post Order 07.003 (rev 10)
Captain of Correctional Officers, to determine if disciplinary action is warranted.
9. CID leadership should review Lieutenant Harvey Haws, for possible policy violation of Post Order 07.006 (rev 6)
Administrative Segregation Officer, to determine if disciplinary action is warranted.
10. CID leadership should review Correctional Officer IV Nicholas Walton, for possible policy violation of Post Order
11. CID leadership should review Correctional Officer V Gerald Defreitas, for possible policy violation of Post Order
12. CID leadership should review Correctional Officer V Aaron White, for possible policy violation of Post Order 07.102
(rev 6) Chain Officer, to determine if disciplinary action is warranted.
13. CID leadership should review Correctional Officer II Brantley Stewart, for possible policy violation of AD 03.72 (rev
6) Offender Property, to determine if disciplinary action is warranted.
14. CID leadership should review Sergeant Kristopher Sharp, for possible policy violation of Security Memorandum 03.02
(rev 7) Security Searches, to determine if disciplinary action is warranted.
15. CID leadership should review Correctional Officer IV Michael McElhaney, for possible policy violation of Security
Memorandum 03.02 (rev 7) Security Searches, to determine if disciplinary action is warranted.
16. CID leadership should review Correctional Officer IV Damion Lawson, for possible policy violation of Administrative
Directive 03.72 (rev 6) Offender Property, to determine if disciplinary action is warranted.
17. CID leadership should review Correctional Officer IV Tanya Miller, for possible policy violation of Administrative
Directive 03.72 (rev 6) and Post Order 07.006 (rev 6) Administrative Segregation Officer, to determine if disciplinary
action is warranted.
18. A review of video surveillance should be compared to documented security rounds to determine if disciplinary action
is warranted on staff falsely documenting rounds.
19. Classification and Records should review SPD codes for inmates with “EX” to determine if they are correctly coded.
Page 11 of 14
Executive Summary
20. Classification and Records should review Classification Profiles to ensure all inmate photos are updated every three
years.
Observations:
1. A third seat was available for an additional correctional officer to provide security on the transport but was not filled
due to staffing. Consideration should be given to require a third correctional officer on all transports involving
restrictive housing and capital murder sentenced inmates. In addition, consideration should be given to allow non-CDL
carrying correctional officers to hold security as a third correctional officer on transport buses and/or as drivers for van
transports to ease the staffing burden.
2. The transport bus driver’s mirror does not provide a full visual of what is directly behind the driver. Consideration
should be given to add an additional mirror at the bottom of the dash to face the bottom of the restrictive housing
compartment door to enhance the visual monitoring of the area behind the driver.
3. Expanded metal along the bottom of the divider between the restrictive housing compartment and front compartment
needs to be enhanced. Consideration should be given to install jail steel mesh or square tubing for additional strength.
4. Transport buses are not equipped with video monitoring capabilities. Consideration should be given for a
comprehensive video surveillance system with recording capabilities and a monitor in the rear officer compartment for
viewing during transport for an enhanced visual of the inmate compartments during transport, as well as video
surveillance documentation in the event of an incident.
5. With the expanded metal security package, age of plexiglass sheeting, and a fully loaded occupancy of inmates, visual
observation is impeded. Consideration should be given to the implementation of a scheduled (3 year vs. 5 year)
replacement program for plexiglass when visibility becomes impaired.
6. The seat located in the rear officer compartment of the bus faces the right side of the bus and sits low. Consideration
should be given to rotate the rear officer seat 90 degrees and raise it higher to aide in the visual observation of the
passenger area.
7. Truck mail at times becomes a safety and security issue in the rear of the bus. Truck mail bags were observed as
excessive and blocked the full view of the rear assigned officer; limited access to movement; and obstructed access to
the fire extinguisher, the shotgun during transport, and the back exit door. Consideration should be given to transport
truck mail via freight or first-class mail.
8. The current tracking system of all transports at ITH are through a cellphone-based system, which does not provide
clear, real-time data due to signal strength in rural areas of the state. Consideration should be given for the installation
of a permanent GPS tracking and monitoring system on each transport bus for enhanced safety and security purposes.
9. The Transport Card does not accurately depict the current look of the inmate. Consideration should be given to allow
Inmate Transportation staff to have a tablet or device to take a current photo of inmates transported as they load the
bus for potential positive identification in the event of an incident.
10. A sampling of restraints reviewed at ITH resulted with a discovery of three models of hand restraints utilized by inmate
transportation, along with three different black boxes. When examined side by side, it was noted the models’ connecting
chain vary in length slightly. Each combination, when crossed with another, potentially exposed the access to the
keyhole on the restraints. One black box model was noted as being altered, with the edge (notch) of the interior outline
to facilitate restraint housing. Consideration should be given for a systemwide review of all black boxes and transport
restraints of various models and replacement with one model of hand restraint that matches one design of black box.
11. Inmate Transportation administration expressed there is a road sergeant or mobile supervisor program to randomly
observe field operations quarterly. However, sergeants are often utilized to conduct scheduled transports, therefore
routine observations have not taken place. Administrative rounds of captain through assistant warden also could not be
Page 12 of 14
Executive Summary
identified as taking place either through verbal confirmation or documentation. Consideration should be given to create
a system to document rounds being completed for evaluation of operations with these random observations and to
ensure they are being completed. These rounds should include the review of video surveillance, when applicable, at
unit locations to ensure transporting staff are compliant with transportation policies and procedures. Consideration
should also be given to add verbiage to post orders for sergeant through major outlining the requirement for Inmate
Transportation supervisors to perform unannounced observations for transports, to include procedures for loading and
unloading of inmates to ensure adherence agency protocols, as well as video surveillance review.
12. Restrictive housing inmates were allowed to wear two-piece whites and personal shoes during transport. Consideration
should be given to require restrictive housing inmates to wear a jumper and slide type shoes for all future transports.
13. Restrictive housing inmates were allowed to maintain their full clothing upon being strip searched and exiting their
designated housing to a holding cell to await transport. Consideration should be given to require inmates exit their
assigned cells in their boxers and slides only en route to the holding cell to reduce the opportunity for hiding of
contraband. Consideration should also be given to modify existing search holding cells with thick Lexan to allow for
an unobstructed view.
14. Strip searches of outgoing inmates were being performed utilizing the 12 building A/B legal booth. Consideration
should be given to conduct strip searches in an area with a clear and direct view of the inmate, free from obstruction.
15. Interviews with inmates leaving on chain May 31, 2022 revealed they were aware of the transfer a minimum of two
days prior to transport to include layover duration. Consideration should be given for all departments with knowledge
of future appointments and transports to be required to train staff on the importance of confidentiality for security
purposes.
16. Conversations with responding entities to the field command operations indicated it was difficult, at times, to determine
the identity of field incident commander. Consideration should be given to utilize a lanyard type system to recognize
the incident commander.
17. Inmate Transportation staff do not currently carry any type of Carry-on-Person (COP) chemical agents. Consideration
should be given to issue foam COP to all Inmate Transportation staff as a secondary measure of defense while in
transport status.
18. Inmate Transportation staff are issued a quick release clip for the assigned holster. Consideration should be given to
modify the holster to one that is directly attached to the duty belt.
19. There is currently not a SPD code for inmates being sentenced as Capital Murder. Consideration should be given to
the addition of a new SPD code for Capital Murder.
20. Current mail procedures do not require a notification process to unit administration of denials of publications.
Consideration should be made to add the requirement of unit administration notification for denied publications that
are of security concerns.
21. Pack canines were utilized during this incident with limited success. Consideration should be given to refocus agency
efforts to strengthen the pack canine program by improving staff knowledge and training capabilities.
22. Scent specific canines were utilized inside the perimeter, but potentially contaminated the track. Consideration should
be given to allow for some scent specific canines, outfitted with a GPS tracker, to be tracked by handlers on horseback
in situations where cross contamination could be an issue.
23. Each CID region conducts kennel drills throughout the year, and unit-based site locations participate in tabletop drills
regarding escapes periodically. Consideration should be given for an annual agency tabletop exercise of an escape
exercise to address and root out potential shortcomings.
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Executive Summary
24. The number of transports conducted daily by Inmate Transportation is high. Consideration should be given to allow a
selected team to review the necessity of all transports to include, but not limited to, non-routine, unit assignment, and
medical appointments. Consideration should also be given to transport identified high risk restrictive housing inmates
by special transport.
25. Technology is available to place GPS trackable ankle monitors for each high-risk restrictive housing inmate being
transported. Consideration should be given to extend an opportunity for outside vendors to make presentations at the
next Technology Review Team meeting to show product availability and performance.
Page 14 of 14
Lopez Escape Review
Final Report – September 2022
TABLE OF CONTENTS
EXECUTIVE SUMMARY ............................................................................. 1

CHAPTER 1: BACKGROUND/METHODOLOGY ........................................ 8
CHAPTER 2: ESCAPEE INFORMATION ................................................... 10
CHAPTER 3: TDCJ BACKGROUND ........................................................ 12
CHAPTER 4: ESCAPE TIMELINE/DESCRIPTION ........................................ 21
CHAPTER 5: EVALUATION OF POLICIES/TRAINING PRACTICES .............. 32
CHAPTER 6: TDCJ CORRECTIVE ACTIONS ............................................. 37
CHAPTER 7: CGL RECOMMENDATIONS................................................ 42
Executive Summary
Executive Summary
On May 12 at 10:21 a.m., inmate Gonzalo Artemio Lopez (ID# 1349716) was placed in a
secure section of a Texas Department of Criminal Justice (TDCJ) bus for transport to the W. J.
Estelle Unit for a routine appointment. Slightly over 2 ½ hours later, inmate
Lopez had removed his restraints, cut his way out of the secure section of the transport bus,
attacked a transport officer, and escaped from custody. Twenty-one days later, inmate Lopez
was located and killed in a shootout with authorities. The serious consequences of this escape
cannot be understated. A correctional officer was attacked and stabbed multiple times and
authorities report that five innocent citizens lost their lives at the hands of inmate Lopez.
Evaluating a serious incident such as the Lopez escape requires a detailed review of the
appropriateness of applicable agency policies, staff practices related to the incident, as well
as understanding the environment and conditions in which the incident occurred. CGL’s
analysis indicates that short staffing resulting from unsustainably high vacancy rates and a
series of lapses in compliance with TDCJ security practices were the primary factors in
facilitating the escape of inmate Lopez.
TDCJ Environment/Conditions. Like most correctional systems in the United States, TDCJ has
faced unprecedented challenges in the last 2 years. The COVID-19 pandemic has altered
and stressed every aspect of correctional facility operations, from the acceptance of inmates
into the system, to the housing, management, and programming of the inmate population.
The growing number of correctional officer vacancies, exacerbated by COVID, has reached
crisis proportions in the state correctional system.
Exhibit 1: Correctional Officer Vacancies/Vacancy Rate
8,000 7,598 7,613

7,000
6,000
5,000 4,524 4,302
3,653
4,000 3,436
3,000
2,000
1,000
-
Dec. 31, 2017 Dec. 31, 2018 Dec 31, 2019 Dec. 31, 2020 Dec. 31, 2021 Apr. 30, 2022
Vacancy
14.1% 13.3% 17.6% 17.6% 31.6% 32.3%
Rate
TEXAS DEPARTMENT OF CRIMINAL JUSTICE

LOPEZ ESCAPE REVIEW – FINAL REPORT
PAGE 1
Executive Summary
In the last 2 years alone, correctional officer vacancies have risen from 4,302 to 7,613, an
increase of 77 percent. Over 32 percent of all correctional officer positions were vacant in
April 2022.
Correctional officer vacancy levels vary by facility and region of the state depending on the
available labor market and the competition for jobs. At the Hughes Unit, where inmate Lopez
was housed, correctional officer vacancies were even more pronounced (Exhibit 2).
Exhibit 2: Hughes Unit Correctional Officer Vacancies/Vacancy Rate

250 235.5
200 192.5
157.5
150
100 85.5 92
50 39
0
Vacancy
* 7% 28% 15% 16% 35% 43%
Rate
In the month prior to the escape (April 2022), 43 percent (235.5 out of 547.5 authorized
positions) of the Hughes Unit correctional officer positions were vacant.
The reality of this severe correctional officer shortage is experienced on a daily basis by
custody supervisors responsible for filling required security posts on each shift. TDCJ has
identified “Priority 1 Positions” that must be filled on each shift at each facility. Per policy,
Priority 1 Positions are those posts that must be filled by custody staff for the “basic security
and operational needs” of the facility. Closing a Priority 1 Position requires the approval of a
regional director. But because of inadequate levels of correctional officers, operating with a
high number of closed Priority 1 Positions has become routine. This was especially true at the
Hughes Unit on the day of the escape where 42 of the 160 Priority 1 Positions were closed
due to staff shortages.

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Executive Summary
Exhibit 3: Hughes Unit Priority 1 Position Vacancies
Priority 1
Closed
27%
Priority 1
Filled
73%
Data for 2nd shift May 11 and 1st shift May 12, 2022
Due to correctional officer shortages, 27 percent of the Priority 1 Positions were closed on the
2 shifts that prepared inmate Lopez for transport (Exhibit 3).
These staff shortages required the remaining staff to carry a heavier workload and increased
the amount of overtime they were assigned. This contributed to establishing a weakened
security environment that better facilitated inmate Lopez’s escape.
Security Lapses. While these staffing shortages, especially at the Hughes Unit, may have been
a factor in inmate Lopez’s ability to escape, they are not an excuse for the multitude of
security lapses that occurred in preparing Lopez for transport. TDCJ, like most correctional
systems, builds multiple redundancies into their practices to ensure that one single failure
cannot have catastrophic results. History shows that when serious incidents of this type occur
in a correctional setting, it is not a single failure that leads to the incident, but the compilation
of multiple failures. That was the case with the Lopez escape. The combination of several
inadequate strip searches, failure to search property, poorly applied restraints, and other
security shortcuts improved Lopez’s probability for a successful escape. The fact is that if one
of these actions was followed in compliance with existing policy, it is likely that the escape
could have been prevented.
Lapses Appear Endemic. TDCJ’s internal review as well as our independent assessment found
that staff at the Hughes Unit had become complacent, and circumvented security procedures
in favor of hastily completing responsibilities in a cursory manner. These breakdowns appear
to have become routine and a matter of regular practice rather than isolated incidents.
Although we did not investigate practices at other TDCJ Units, it is possible that the
complacency regarding security practices is occurring there also.

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Executive Summary
Lack of Supervisory Oversight. Supervisory oversight is key to ensuring staff compliance and
preventing staff complacency. However, as noted in TDCJ’s Serious Incident Review,
supervisory security staff had not been conducting regular inspections or routine rounds.
Additionally, we found there is no policy that identifies when/where facility leadership are to
conduct rounds and the frequency of those rounds. Also, existing surveillance systems can be
better used to provide oversight, and the Hughes Unit has a significant number of remote
surveillance cameras. But the ability to review the enormous amount of video captured on
these camaras is difficult and makes it very time-consuming for supervisor’s to remotely
observe staff compliance.
TDCJ Response to Incident. TDCJ implemented a multitude of corrective measures outlined in

Chapter 6 to address the deficiencies found during their own internal review and also took
the unconventional step of suspending inmate transports for a week so that it could dedicate
its limited resources to reviewing transportation practices. CGL fully agrees and supports
those corrective actions. The following recommendations would further address the conditions
that made the escape of inmate Lopez possible.
CGL Recommendations. The following 19 recommendations address additional issues

required to improve facility and transport security:
1. Recruitment and Retention. Underlying many of TDCJ’s issues is the lack of staff in the
correctional officer position. TDCJ and the State of Texas must continue their efforts to
recruit and retain staff. The recent salary increase for line staff is a positive step.
2. Focus Security Assessments on Search and Transport Procedures. As TDCJ
reimplements its security review process, it should focus these reviews on basic security
practices and transportation security.
3. Review Medical Transports with UTMB for Appropriateness. TDCJ has begun efforts to
reduce transports through increased telemedicine and expanding on-site services.
Telemedicine equipment is reported to be outdated and should be upgraded.
Additionally, TDCJ should conduct a data-driven analysis of past medical transports to
determine areas where medical appointments could be conducted without transport.
4. Reorganize/Streamline TDCJ’s Policy Structure. Policies function as a rule book for
staff conduct and performance and should be clear and easy to understand. TDCJ’s
policy structure is one of the most complex we have found in any state correctional
system, with requirements spread across a significant number of different policy
sources. Simply finding a TDCJ policy requirement is an extremely time-intensive and
difficult undertaking for any staff, or outside consultant. TDCJ should engage a study
to streamline their policy structure, improve their clarity, and elevate those important
requirements to require Executive Director approval.
5. Revise Security Precaution Designator Policy. The Security Precaution Designator policy
identifies certain categories of inmates that require enhance supervision including
those with a past history of escape. The policy should be revised to establish more
detail regarding transport requirements for those inmates with an escape history or
other factors or circumstances that may indicated an individual has a higher risk of

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Executive Summary
escape. Currently the policy prescribes only very limited transport implications for
inmates with a recent escape.
6. Pilot Policy Requirement Modifications that Consider Current Staff Shortages.
Developing corrective actions to the escape that load more work on already overtaxed
staff can result in further failures. Given the low staff levels correctional officers are
often require to perform the policy requirements of multiple positions. TDCJ must ask
“Are these policy requirements impossible to achieve given the current staffing crisis.”
In certain circumstances we found this to be the case, and it likely contributes to staff
taking security shortcuts. TDCJ should consider piloting the reduction of some of those
requirements to a more reasonable level during the current staffing shortage.
7. Reinforce Policy Concerning the Prior Notice of Transports. It was discovered that
inmates are routinely provided advanced notice of the date of their upcoming
transports. The Executive Director should issue an order to all employees and
contractors reinforcing that inmates are not to be given advanced notice of the
dates/times of future transports. Policy should also reflect this requirement.
8. Establish a Duty Warden Inspection Schedule. Best practices support establishing
requirements for wardens, assistant wardens, and majors at each facility to conduct
scheduled and unscheduled rounds and personally visit all areas of their facility. No
current TDCJ policy exists. We note that administrative staff did appear to be making
regular rounds at the Hughes Unit, but these rounds were at their own discretion and
were not documented.
9. Require Documented Regional Director Inspections. Likewise, TDCJ should establish a
policy requiring regional directors make a minimum number of inspections on a
quarterly basis in their facilities. This sets expectations for the regional directors.
Additionally, policy should require that regional directors and staff conduct periodic
formal inspections of their unit each quarter, unless a security audit is being conducted
that quarter. These formal inspections should focus on vulnerability and policy
compliance and use an instrument that can be regularly adjusted to meet the primary
concerns of agency leadership.
10. Conduct Desk Audit/Workload Analysis of Warden’s Position. Over the years, an
increasing number of administrative duties have been added to TDCJ’s wardens.
These duties appear to require more and more time behind a desk, reducing the
valuable time they have touring their facilities. TDCJ should audit wardens’ workloads
and make changes necessary to maximize their ability to be present in key areas of the
facility and observe inmates and staff.
11. Reconfigure Transport Buses to Improve Security. The transport buses are equipped
with three staff seats and two compartments:
• Seats:
o Driver Seat
o Rear Compartment Officer Seat
o 3rd Officer Seat
• Compartments
o Restrictive Housing Compartment
o General Population Compartment

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Executive Summary
Exhibit 4: TDCJ Transport Bus Configuration
CGL Recommends:
• Turn 3rd Officer seat to face inmate compartment. Currently the seat faces
forward, directing the officer’s vision away from the inmate compartments.
• Relocate the Restrictive Housing Compartment to the back of the bus: TDCJ
should consider placing the less controlled population (general population) at
the front of the bus and the more controlled (restrictive housing) in back, in
closer proximity to the rear compartment officer and further away from the
driver.
12. Require Random Review of Strip Searches. Failure to adequately perform a strip
search was a major contributor to Lopez’s escape. Random video reviews of strip
searches by supervisors will provide a better understanding of compliance with this
policy. This may require expanding the number of video surveillance staff through the
use of qualified volunteers or others and improving the documentation of when strip
searches occur.
13. Inspect Integrity of Restrictive Housing Cells. During our tour of inmate Lopez’s cell in
the Hughes Unit we found gaps between the wall and the plumbing chase, which
could have allowed for the storage or transfer of contraband. A documented
inspection of every cell in Restrictive Housing units should be immediately conducted.
14. Prohibit Inmates from Retaining Personal Property on Transport. Any inmate property
should be limited and carried either in a chase vehicle or a secure area of the
transport vehicle that does not hinder site lines or limit the amount of property inmates
can take on a medical transport.
15. Require Supervisory Oversight (Lieutenant or Above) of Out-Processing of Any Inmate
for Transport. A lieutenant or above should be required to monitor the sallyport area
where inmates are moved to the transport bus. This area should be secure and free of
other inmates.
16. Enhance Publication Review Notification Practices. TDCJ’s internal review found that,
prior to his escape, inmate Lopez had ordered several publications regarding survival
techniques, weapons manufacturing, and manipulation that should have raised
concerns about his future intentions. These books were shipped to the facility and
appropriately denied upon review by mailroom staff. However, facility administrators
PAGE 6
Executive Summary
were not made aware of these publications as there is no policy requirement for
supervisory notification. If this notification had been made, it is possible Lopez’s
security supervision may have been amplified and his method of transport altered.
17. Eliminate Multiple Security Rosters at Correctional Facilities. The existing practice of
running multiple, separate turnout rosters at each facility can result in more critical
posts being left unfilled in favor of less critical posts. Lopez was housed in the
Restrictive Housing Unit at the Hughes Unit. The Hughes Unit has 2 primary rosters
(general population and restrictive housing) on each shift and these rosters are siloed
and staff were not shared across them to ensure the most critical posts were filled. We
found that on these shifts prior to Lopez’s escape, the general population rosters were
better staffed than restrictive housing rosters. This left critical high-priority restrictive
housing posts unfilled.
18. Address Gaps in Annual In-Service Training. TDCJ acknowledges past gaps in annual
training due to the impact of the COVID-19 pandemic and has begun addressing
those gaps. Also, as part of annual training, the agency should elevate training on key
security lapses identified during the Lopez escape review. These include strip searches,
application of restraints, managing inmates in restrictive housing, and transportation
supervision.
19. Institute Annual Refresher Training for Transportation Staff. Staff hired into the
Transportation Unit participate in the initial Offender Transportation Training Program,
but no annual transportation-specific refresher training is required. TDCJ has recently
implemented a corrective action after the Lopez escape that included requiring
transportation supervisors regularly evaluate transportation officers while preparing
and conducting transports. We recommend this evaluation include some time
mentoring staff on transportation security requirements including searches, restraints,
and supervision.

PAGE 7
Chapter 1: Background/Methodology
On May 12 at 10:21 a.m., inmate Gonzalo Lopez (1349716) was placed in a secure section
of a Texas Department of Criminal Justice (TDCJ) transportation bus for his transport to the
W. J. Estelle Unit for an appointment. Slightly over 2 1/2 hours later, inmate
Lopez had removed his restraints, cut his way out of the secure section of the transport bus,
attacked a transport officer, and escaped from custody. Twenty-one days later, inmate Lopez
was located and killed in a shootout with authorities. During his days on escape, authorities
report Lopez killed 5 innocent individuals.
In June 2022, CGL Companies submitted a proposal relative to solicitation number 696-ES-
22-P036 to conduct “an independent review and comprehensive report of the factors,
policies, and practices that may have contributed to the recent escape of TDCJ inmate
Gonzalo Lopez.” CGL was awarded the contract for this solicitation and the contract was
established on June 20, 2022. The requirements of the contract were:
• Conduct a detailed review of the incident and any supporting materials including
investigative reports, background materials and video recordings.
• Assess existing policies on classification, management and transport of high-risk
inmates and evaluate their effectiveness in managing risk;
• Review all operational, security procedures, standards, practices, protocols, and the
level of compliance with the Departments written security procedures as it relates to
the search and the movement of inmates both internal and external to the Unit;
• Assess staff deployment, vacancy rates, training, and any system-wide factors that
may have had a bearing on the incident; and
• Review Inmate Transportation policies, procedures, protocols, and practice related
to movement of inmates involved in external transportation to courts, hospitals,
transfers to other facilities, other scheduled appointments and the specific practices
related to the transport of inmate Lopez.
This assessment reviews TDCJ’s overall policies and practices, as well as the performance of
staff involved in the housing, staging for transport, and the transport of inmate Lopez.
Report Disclaimer. Independent from CGL’s review of TDCJ’s policies and practices, the State
of Texas is conducting an ongoing criminal investigation. This investigation may determine
whether others (inmates, staff, or civilians) provided aid or support to inmate Lopez’s escape.
CGL’s scope of work for this project was not directed at these criminal matters and therefore
this report does not comment on whether other inmates or staff may have conspired in inmate
Lopez’s escape. Additionally, the scope of the project focuses on issues and actions that may
have contributed to the escape and does not involve an assessment of TDCJ’s emergency
response after the escape occurred.
On June 27th, 2022, the CGL team was on-site at the TDCJ’s administrative offices in
Huntsville, Texas. The CGL on-site team consisted of:

PAGE 8
• Brad Sassatelli: Mr. Sassatelli is a Senior Vice President with CGL and has over 35
years of correctional experience leading and participating in major systems needs
assessments and evaluations. He served as the project manager for this effort.
• Ken McGinnis: Mr. McGinnis is a Senior Vice President at CGL Companies, and
previously served as the Director of the Michigan Department of Corrections from
1991 to 1999 and Director of the Illinois Department of Corrections from 1989 to
1991.
• Gary Maynard: Mr. Maynard served as the Secretary of the Maryland Department of
Corrections from 2007 to 2014, Director of the Iowa Department of Corrections from
2003 to 2007, Director of the South Carolina Department of Corrections from 2001
to 2003, and Director of the Oklahoma Department of Corrections from 1987 to
1992.
• Jeff Beard: Mr. Beard is a correctional expert who was the Secretary of the California
Department of Corrections from 2012 to 2016, and Secretary of the Pennsylvania
Department of Corrections from 2001 to 2010.
Additionally, Dave Runnels served on CGL assessment team, but was not present at the on-
site meetings. Mr. Runnels has over 30 years’ experience working in the criminal justice
system culminating in his appointment as Undersecretary for the California Department of
Corrections and Rehabilitation (CDCR). In this position he was responsible for oversight and
management of all adult correctional operations within the CDCR.
The CGL team spent 2 days at the Huntsville offices meeting with Executive Director Bryan
Collier and his administrative team, reviewing documents, interviewing staff, observing the
operation of the Transportation Unit, inspecting the transport bus used in the escape, and
examining video of Lopez’s transport preparation at the Hughes Unit. The team spent the 3rd
day at the Hughes Unit in Gatesville Texas to observe where inmate Lopez was housed,
prepared for transport, and placed on the transport bus. Additionally, CGL conducted
additional interviews at the facility relevant to the escape.
TDCJ was very forthcoming in this escape assessment, and openly recognized there were
failures to follow proper procedures, as well as existing policy and practice issues.
Additionally, they were responsive in providing a multitude of documents that the CGL team
requested.

PAGE 9
Chapter 2: Escapee Information

Gonzalo Artemio Lopez was a 46-year-old Hispanic male serving a life sentence for Capital
Murder from Hidalgo County, Texas, and a consecutive life sentence for Attempted Capital
Murder from Webb County. He had a significant assaultive criminal history with convictions
for Aggravated Kidnapping, and three counts of Aggravated Assault. He was confirmed as a
member of the Mexican Mafia.
Also in his history is a documented escape attempt. Specifically, while in the custody of the
Hidalgo County Adult Detention Center in 2004, Lopez’s cell was searched, and it was found
that tape was being used to cover a portion of the concrete cell wall that Lopez was
attempting to “dig” through. Upon further inspection three metal pieces were found that were
being used to aid in his effort.
After his conviction Lopez was admitted to TDCJ’s Byrd Unit on February 23, 2006 and was
subsequently transferred to the Connally Unit a few months later. He was later moved to the
Ellis Unit where he was placed in the Gang Renouncement and Disassociation Program
(GRAD) in 2013. He successfully completed the program receiving designation as an ex-
gang member in 2014. He was subsequently transferred to the Hughes Unit in 2016 as the
result of the Security Threat Group office investigation that determined Lopez could be a
target of gang violence at the Ellis Unit.
In the Hughes Unit inmate Lopez was housed in Restrictive Housing in Level 1 Security
Detention status. TDCJ’s Restrictive Housing Plan establishes three separate levels, with Level
1 being the least restricting and providing the greatest number of privileges. The policy
specifically outlines that Level 1 Security Detention is the lowest level used to “designate
offenders who generally maintain good behavior but require separation from general
population offenders. Offenders assigned to this custody may have a history of assaultive
behavior, but the offender’s current behavior, within the last 90 days, is non-assaultive in
nature.”
The classification unit noted that in March 2022, Lopez refused to leave Restrictive Housing to
be placed in general population. CGL requested clarification regarding this refusal and the
Director of Classification and Records noted that while he did not recall the specifics of
inmate Lopez’s housing review, it was not unusual for restrictive housing inmates to refuse a
return to general population as “many mentioned they were comfortable in restrictive housing
where they could live alone without a cellmate. They expressed if they were forced to
intermingle in a general population setting again, they would not be successful and would
find a way back to restrictive housing.” We also note TDCJ’s “Restrictive Housing Plan”
provides allowances for considering the “offender’s expressed desire to remain in, or stated
readiness to be released from, security detention.”
During his incarceration Lopez received 22 minor disciplinary cases and six major cases. One
of those major cases occurred in 2012 where he was found guilty of Sexual Misconduct when
he exposed his genitals to an employee. Another two of those major cases involved

PAGE 10
Fighting/Assaulting another inmate, one with a weapon in 2019 (piece of metal sharpened to
a point) and one without a weapon in 2016. In the 2019 assault Lopez was named as an
assailant in an investigation of the stabbing of inmate Winston Williams (TDCJ ID #704475).
Lopez allegedly loaned Williams a cell phone and the inmate did not return it, which resulted
in the assault where he slashed at Williams with a sharpened piece of metal.
TDCJ Administrative Directive 04.11, Security Precautions Designators allows for a specific
designator to be placed in an inmates file whose behaviors warrant special considerations.
These designators are flags to staff that may impact how that specific inmate is managed and
housed. In classification records, Lopez had an existing security precaution designation of
“ES” which would indicate he had a history of escape in the past 10 years. This was in error
as his escape history occurred in 2004 which should have resulted in an “EZ” designation
(Escape Precaution Designator More than 10 Years Old.). The impact of these designations
on inmate management and transports is minimal. Those inmates with the higher designation
(ES) are not eligible for assignment to a lower custody level. There are no defined
implications on transport practices for inmates with either of these designations. The Security
Precautions Designator policy and the Transport Officer Post Orders only indicate the need to
ensure the transportation staff are aware of the designation.
Lopez’s medical history included and ( ) after

having in March 2021. He was being monitored by UTMB
for and had been in 2014. He had recently been
complaining of and submitted a . He was referred to the
clinic and an appointment was scheduled to occur at the Estelle Unit on May
13, 2022. On May 12, 2022, he was being transported to the Estelle Unit for this
appointment when he escaped.

PAGE 11
Chapter 3: TDCJ Background

TDCJ is the largest state correctional system in the country, supervising over 118,000
inmates. The next largest prison systems are California (96,733 population – August 10,
2022) and Florida (80,495 – June 2021). TDCJ’s population is managed in 98 correctional
facilities spread across Texas. These facilities operate under TDCJ’s Correctional Institutions
Division (CID) and Private Facility Contract Monitoring/Oversight Division (PFCMOD).
Like most other correctional systems, TDCJ’s prison population levels have fallen since 2019
due primarily to the COVID-19 pandemic.
Exhibit 5: Historical TDCJ Inmate Population

160,000
146,038 145,082 141,549
120,873 119,498 118,081

120,000
80,000
40,000
0
Between 2017 and 2019, the inmate population fell gradually, before a substantial decrease
in 2020. Overall, since 2017, the inmate population housed in TDCJ has decreased by a by
19.1 percent (27,957). This decrease has allowed TDCJ to idle or close multiple facilities.
Inmate Lopez was housed in the Alfred D. Hughes Unit (Hughes Unit) located in Gatesville
Texas. The prison was opened in 1990 and is in a rural section of central Texas,
approximately 2 hours south of Dallas. The Hughes Unit is a 2,984 male multi-custody facility
that can house general population inmates as well as restrictive housing and those that
require safekeeping. The facility includes 12-Building where Lopez was housed, which has
420 mental health and 84 restrictive housing beds.
Agency Staffing. For the past few years, correctional systems across the US have faced a
growing staffing crisis. While this issue began before the COVID-19 pandemic, it has grown
worse in the past two years, partly fueled by virus-related absenteeism that has increased
workload demands, created excessive levels of overtime, and ultimately made employment in

PAGE 12
a correctional facility less attractive. When coupled with a national labor shortage, systems
have struggled to meet their daily workload requirements.
TDCJ has experienced significant recruitment and retention issues in the last 2 years resulting
in falling staffing levels.
Exhibit 6: Total TDCJ Staff

50,000
40,000 35,717 36,257 35,066

33,194
29,020 29,041
30,000
20,000
10,000
0
Since 2017, total agency staffing levels have dropped by 18.7% (6,676) from 35,717 on
December 31, 2017, to 29,041 on April 30, 2022, immediately before inmate Lopez
escape.
However, the decrease in overall agency staffing, understates the real staffing issue TDCJ is
facing. Most of the vacancies in the agency are in the Correctional Officer position. Exhibit 7
provides the number of filled Correctional Officer positions since 2017.

PAGE 13
Exhibit 7: TDCJ Filled Correctional Officer Positions
25,000
22,160 22,405
21,214
20,107
20,000
16,420 15,948
15,000
10,000
5,000
-
Correctional Officer staffing levels have dropped significantly in the past 5 years falling by
over 6,000 full-time equivalent positions (FTEs). This decrease was at least partially
attributable to facility closings. A metric that more accurately tracks correctional officer
vacancies is shown in Exhibit 8.
Exhibit 8: Correctional Officer Vacancies/Vacancy Rate
8,000 7,598 7,613

7,000
6,000
5,000 4,524 4,302
3,653
4,000 3,436
3,000
2,000
1,000
-
Vacancy 31.6%
Rate 14.1% 13.3% 17.6% 17.6% 32.3%

PAGE 14
Since December 2020, correctional officer vacancies have risen from 4,302 to 7,613, an
increase of 77 percent. Over 32 percent of all correctional officer positions were vacant in
April 2022.
Hughes Unit Staffing. The correctional office shortages were even more serious at the Hughes
Unit, where inmate Lopez was housed.
Exhibit 9: Hughes Unit Correctional Officer Vacancies/Vacancy Rate
250 235.5
200 192.5
157.5
150
100 85.5 92
50 39
0
Vacancy
* 7% 28% 15% 16% 35% 43%
Rate
In the month prior to the escape (April 2022), 43 percent (235.5 out of 547.5 authorized) of
the Hughes Unit correctional officer positions were vacant. However, this 43 percent vacancy
rate actually understates the seriousness of the issue at the facility. In addition to those vacant
positions, high turnover further reduces the number of correctional officers who can fill a post.
CGL was informed the Hughes Unit had 96 correctional officers leave employment in the first
6 months of 2022. These vacant positions must be filled with newly hired COs who must
spend their initial 6 weeks in pre-service academy training. During time in pre-service
training, they also are unable to fill a post.
The high turnover also means less experienced staff. From August 2017 to May 2021, the
average tenure of a CO at the Hughes Unit decreased by 25 months (from 86 months to 61
months), resulting in the facility being supported by an increasing number of inexperienced
staff.
Shift supervisors, who are responsible for scheduling staff for each shift, face the reality of
staffing shortages every day. Our review of shift rosters on the day of the Lopez escape clearly
displays the challenges they face.

PAGE 15
As background, prison shift rosters identify posts that are to be filled on each shift and are
built from post plans developed for each facility by TDCJ’s Corrections Institution Division.
These post plans (also known as shift “turnout rosters”) are developed for each shift, and list
the security posts, and the priority in which each post should be filled. On each day’s shift,
the turnout roster is used as the guide for filling posts and serves as a record documenting the
staff who were assigned to each post.
TDCJ’s Administrative Directive AD-11.52, Security Staffing defines the priority in which posts
are filled:
• Priority 1 Positions. Priority 1 positions are any post that is needed to meet the basic
security and operational needs of the unit. Agency policy requires a regional director
approval in instances where a Priority 1 post cannot be filled.
• Priority 2 Positions. Priority 2 positions are any post that the warden or designee may
staff as needed that are deemed necessary based on the availability of staff. Therefore,
Priority 2 posts are filled when a shift has excess staff for Priority 1 posts.
• Position Deviation. A position deviation occurs when staff are deployed to a post that
is not designated on the turnout roster. These are typically intermittent posts for
unplanned events such as unexpected transports, supervision of an inmate placed in a
hospital, or supervision of inmates placed on some level of suicide watch. Position
Deviations must be filled and, as a result, increase security staffing needs when they
exist.
Due to the chronic correctional officer shortage in TDCJ, it has become commonplace for a
significant number of Priority 1 posts to remain unfilled on each shift.
This was especially true at the Hughes Unit where the turnout roster for each of the two 12-
hour shifts typically has fewer staff available than it has Priority 1 posts. CGL reviewed the
Hughes Unit Restrictive Housing Turnout Rosters for the two shifts that had responsibility for
preparing Lopez for transport (2nd shift on May 11 and 1st shift on May 12, 2022).

PAGE 16
Exhibit 10: Hughes Unit Restrictive Housing Rosters
Restrictive Housing Turnout Restrictive Housing Turnout

Roster Roster
nd nd
2 Shift, May 11, 2022 1st Shift, May 12, 2022
Post Requirements
# Of Priority 1 Posts 24 31
Number of Position 6 3
Deviations on shift
Total Posts Needing Filled 30 34
Staff Availability
Staff Assigned to Shift 16 21
Staff Available to fill post 7 18
Staff on Overtime 11 3
Priority 1 posts Filled 14.5* 18.5**
% Of Priority 1 Posts Unfilled 40% 40%
*Staff alternate posts every 4 hours. On the 2nd Shift, May 11, 2022, 13 Priority 1 posts were filled for the entire
8-hour shift, while 3 were filled only for 4 hours.
** On the 1st shift, May 12, 2022, 15 posts were filled for the entire 8-hour shift in addition to 7 posts being
filled only for 4 hours.
Staff began readying inmate Lopez for transport on the 2nd shift on May 11, 2022. As shown
in Exhibit 10, that shift required 24 Priority 1 posts on the Restrictive Housing Turnout Roster.
Six additional (deviation) posts had to be filled (mental health watches, hospital security,
transports), bringing the total number of posts needed to be filled to 30. However, due to the
staffing shortage, 16 COs were assigned to work that day, and only 7 of those were present
for the shift. Essentially, there were only 7 COs on that shift to fill 30 posts.
To partially compensate for the lack of staff on this shift, 11 staff were brought in on voluntary
overtime, which allowed for 14.5 of the 24 Priority 1 posts to be filled along with the 6
deviated posts. Forty percent of the Priority 1 Posts were left unfilled.
The 1st shift on the following day experienced similar shortages resulting in 40 percent of the
Priority 1 posts unfilled. The staffing levels for these 2 shifts were typical of what the Hughes
Unit had been regularly facing.
Transportation Unit. TDCJ’s Transportation Unit is responsible for conducting all inmate
transports across the agency. These include transports between facilities, transports to outside
medical consults and transports from county jails. The Transportation Unit has also been
impacted by correctional officer shortages.

PAGE 17
Exhibit 11: Transportation Unit Filled Correctional Officer Positions
400
350
300 284 287 288 283

274
250 234
200
150
100
50
0
August 2017 August 2018 August 2019 August 2020 August 2021 May 31, 2022
Vacancy
Rate 3.4% 2.4% 8.9% 10.4% 13.3% 25.9%
The number of filled CO positions in the Transportation Unit decreased by 50 since August
2017, a drop of 18 percent. By May 2022, over 1 in 4 transportation unit CO positions were
vacant (25.9 percent vacancy rate).
However, the Transportation Unit workload also decreased during this timeframe as shown in
Exhibit 12.
Exhibit 12: Transportation Unit Workload Metrics – FY17 to FY22
Total Inmates Total Miles

Transported Driven
FY 2017 584,948.00 4,867,516.50
FY 2018 586,742.00 4,816,691.90
FY 2019 577,970.00 5,081,335.30
FY 2020 386,139.00 4,595,255.20
FY 2021 280,475.00 4,966,741.50
FY 2022* (annualized) 339,625.29 4,345,712.19
Decrease since FY 2017 -245,332.71 -521,804.31

% Decrease since 2017 -42% -11%
From FY 2017 through FY 2022, the annual number of inmates transported declined by over
245,000, a 42 percent decrease. The number of miles driven by the unit decreased by a
lesser amount (11 percent). These decreases are primarily due to the impact the COVID-19
pandemic had on inmate movement in the agency. The disparity between the decrease in
number of inmates transported and the total miles driven is also a function of the pandemic

PAGE 18
as TDCJ reduced the number of inmates on each transport to mitigate the transmission of the
virus.
The organization of the Transportation Unit is divided into separate regions with the Central
Region Transport (CRT) being responsible for the Lopez transport. CRT staffing levels on the
day of the Lopez transport are provided in the following exhibit:
Exhibit 13: CRT CO Staffing – May 12, 2022
Allocated Positions 117

Vacancies 42
Filled Positions 75
Staff on Leave/Inservice/Duties Outside CRT 17

Staff Available to Fill a Post 58
On the day of the transport, CRT was allocated 117 COs but had 42 vacancies, a 36
percent vacancy rate. Seventy-five CO positions were filled but 17 of those were on some
form of leave, in training, or providing support to Operation Lone Star (an intergovernmental
task force to address issues with illegal immigration). This resulted in 58 CO’s being available
on that day, resulting in a functional vacancy rate of 51 percent.
CRT requires certain support posts be filled in its headquarters to serve as dispatchers and
perform administrative duties. On May 12, 11 FTEs were dedicated to this support function
leaving the remaining 47 CO’s responsible for conducting 23 transports. Six of those 47 staff
were newer employees who were in on-the-job training status.
It was reported to the CGL Team that transports formerly required 3 staff, but this was
reduced to 2 staff several years ago. Our review of agency policies found the only reference
to the number of staff required per transport is in the Transport Officer Post Order issued
under the authority of the Director of the Correctional Institutions Division dated May 14,
2018, which states:
“A minimum of two transport officers shall be used on any transport assignment. Additional
transport officer or a security supervisor may also be used if warranted.”
Given the CRT staffing levels of 47 COs for 23 transports on May 12, 2022, only two of the
transports were able to have a 3rd officer, and in both cases that 3rd officer was a new
employee who was in on-the-job training status (OJT). Which transports are selected to have
a 3rd officer are more a function of the length of the run than the type of inmate transported.
OJT officers are generally assigned as a 3rd officer to transports that of are an extended
length and duration. This allows the two other officers to split driving responsibilities.
Summary. Staffing shortages at the line staff level (correctional officer) are at a critical level
for TDCJ, with the potential to impact their ability to house and transport inmates in a safe

PAGE 19
and secure manner and provide needed programs and services. This was apparent at the
Hughes Unit where inmate Lopez was housed, which had 40 percent of their Priority 1 posts
unfilled on the shifts that were responsible for ensuring the safety and security of his transport.

PAGE 20
Chapter 4: Escape Timeline/Description

Transport Rationale/History. Inmate Lopez’s May 12, 2022, transport was predicated on the
need for an at the Estelle Unit. He had a history of a
and had recently identified concern with . Medical clinics are provided
regionally within TDCJ through their contract with the University of Texas Medical Branch
(UTMB). The Estelle Unit provided a regional . Lopez had several
previous transports for medical needs.
Description of Escape. CGL understanding of the events leading up to the escape were the
result of the following:
• A review of a considerable number of policies, procedures, and documents provided
by TDCJ.
• Interviews with TDCJ staff.
• Review of video evidence from the Hughes Unit displaying the preparation of Lopez for
the upcoming transport.
• Inspection of the Hughes Unit and the transport bus used in the escape.
Preparation for Transport by Hughes Unit Staff. In preparation for his off-site medical
appointment, custody staff at the Hughes Unit arrived at inmate Lopez’ cell early on May 12,
2022, to begin the process of readying him for that day’s medical transport. Prior to
transport, per the “Chain Officer” Post Order, an inmate’s personal property must be
inventoried in accordance with AD-03.72, “Offender Property.” The Offender Property
directive requires staff document the property in the offender’s possession.
TDCJ policy requires that restrictive housing inmates are strip searched prior to leaving their
cell and any property they have be thoroughly searched. TDCJ Policy1 defines a “strip search”
as the “observation of an offender with all clothing removed to permit a total visual inspection
of the offender’s body. Clothing shall be searched while removed from the offender.” Policy
also requires that any Restrictive Housing inmate must be strip searched prior to exiting their
cell. This strip search is performed by staff who are to stand outside the cell and direct the
inmate (who remains in the cell) through the strip search requirements.
At 12:48 a.m. on May 12, 2022, Officer Randall Smith (CO Smith) arrived at Lopez’s cell
(33) in unit 12F and issued Lopez two red bags for transport (chain bags) to pack his
personal property prior to the transport. At 1:26 a.m. CO Smith returned to Lopez cell front
along with CO Bernard Guishard (CO Guishard). CO Guishard opened the cell door
allowing Lopez out of his cell. This action violated TDCJ policy and sound security practices
requiring all restrictive housing inmates be strip searched prior to being allowed out of their
cell. Additionally, no hand restraints were placed on Lopez prior to opening the cell door.
1
AD-03.22, Offender Searches
PAGE 21
Lopez then handed CO Smith a bag of

his (Lopez’s) property. CO Smith then,
apparently at the request of inmate Lopez,
walked to the front of inmate ’s cell
(# ) who was 3 cells away and
sat the property in front of the cell, while
gesturing at . This action is also in
non-compliance with TDCJ policy and
sound security practices. Transferring
property between inmates is considered
“trading and trafficking” and could be in
support of payment for some form of
debt. Additionally, staff did not search the
property.
At 2:05 a.m. Sergeant Joshua Watson (Sgt.

Watson) came to the front of inmate
’s cell where he opened the pass-
through on the cell front and handed
Lopez’s red property bag through. Again,
this was done without any search of the
property bag an in non-compliance with
agency policy.
At 9:34 a.m. Correctional Officers

Gerardo Velasquez (CO Velasquez) and
Dillon Miller (CO Miller) approached
inmate Lopez’s cell to prepare him for
removal. These officers begin the strip
search process, but video evidence reveals they only conducted a cursory search and fail to
follow required strip search procedures. Specifically, staff did not maintain constant
observation of Lopez in his cell during the search. The staff can be seen talking among
themselves and looking away from the cell. Additionally, Lopez’ clothing was not thoroughly
searched.

PAGE 22
A short while later, video shows inmate

Lopez passing his hands through the
door pass-through and hand restraints
are applied by CO Velazquez. Lopez is
removed from his cell by the officers
and is seen on video carrying his
mattress and blanket behind his back
(while handcuffed from behind). In
violation of policy, he is allowed to
walk in front of inmate ’s cell
and drop off the items.
Lopez is then escorted to a small room

in 12-Building by CO’s Velasquez and
Dillon typically used for legal visits (A/B
Legal Booth). He is secured in the
room.
At 10:18 a.m., Transportation Correctional Officer Jimmie Brinegar (TCO Brinegar) and CO
Miller arrive at the A/B legal booth. TCO Brinegar initiated the strip search of Lopez by
standing outside the room, opening the pass-through and having Lopez hand him his
clothing for search. The search of clothing was not as thorough as required, as TCO Brinegar

PAGE 23
also did not instruct Lopez to complete all the required elements of a strip search, and
constant observation of Lopez was not maintained. Part of the issue was that the room was
not appropriate for observing a strip search through the door given the door’s construction
which obscures the line of sight. CO Miller and another correctional officer were also present
outside the room but were not observing the strip search while it took place.
At the completion of TCO Brinegar’s strip

search (10:21 a.m.) Lopez passed his hands
through the door pass-through and hand
restraints were applied. Additionally, TCO
Brinegar applied a “cuff protector”. Cuff
protectors (also called “black boxes”) are
placed between the handcuffs to block
inmates from manipulating the hand
restraints and having access to the keyhole.
An internal review after the escape found
that some cuff protectors did not fully cover
the keyholes in the hand restraints, which
may have allowed inmate Lopez to
manipulate the mechanism in his escape.
After the A/B legal booth opened, leg restraints were applied to Lopez over his pantleg,
causing them to fit loosely around inmate Lopez’s leg. Lopez is allowed outside the AB Legal
Booth and escorted out of the building by TCO Brinegar and CO Miller. During this escort
out he is directed past a device that screens inmates for the presence of metal on their
person. This device, known as the Body Orifice Security Scanner or “BOSS Chair” is designed
to quickly detect metallic contraband within body cavities of inmates. Agency Policy requires
restrictive housing inmates be scanned in the BOSS chair prior to be placed on a transport.
This device was not used on inmate Lopez.

PAGE 24
At 10:24 a.m. Lopez was

escorted outside of 12-
Building into a sallyport area,
where inmates are placed on
the bus. This area should be
free of other inmates during
transport preparation, but
video review found a large
number of inmates in this area
at the time Lopez was being
escorted through it. In this
area, his identity was verified
by staff, and he was provided
a sack meal for transport.
Immediately following, Lopez is escorted onto the transport bus by TCO Brinegar and CO
Miller and reported to be placed in the restrictive housing compartment that separates those
inmates from general population. This section is immediately behind the bus driver’s seat,
and is secured by a front and back door, metal supports, expanded steel, and Plexiglas.
Both CO’s left the area while Transportation Correctional Officer Randy Smith (TCO Smith)
remained behind loading property into the underbody storage of the bus. TCO Smith then
departed from the area for an extended period, leaving the bus and its occupants
PAGE 25
unsupervised. This is in violation of TDCJ’s Transport Officer Post Orders that states “At no
time during the transport of offenders shall the vehicle be left unattended.”
At 10:56 a.m. the transport bus was fully loaded with 9 general population and 7 restrictive
housing inmates and exited the 12-building sallyport heading for the Hughes Unit back gate.
When the bus pulled between the double sallyport back gates, the Back Gate Officer used a
mirror to search under the vehicle and within the engine compartment. However, the Post
Orders for the Back Gate Office require they “maintain an accurate count of all offenders
entering and exiting the unit.” Video review did not find the Back Gate Officer conducting
any count of inmates on the bus.
During our time on-site, CGL team members inspected the bus that was used to transport
Lopez. It was manufactured by the Blue Bird Body Company with a manufacture date of April
2014. The interior layout of the bus and the restrictive housing and general population
compartments are common for TDCJ’s transport buses.
Exhibit 14: Transport Bus Configuration
3rd Officer Seat

(Not filled)
Restrictive General
Housing Population
Compartment Compartment
Driver Seat Rear Compartment

Officer
The transport buses have 3 officer seats:

• Driver seat
• Rear Compartment Officer seat separated from the general population seating by
metal and Plexiglas
• 3rd officer seat – only filled if 3rd officer is on transport (vacant during Lopez transport)
The inmate seating areas are broken into two separate compartments. The Restrictive
Housing compartment is located immediately behind the Driver and 3rd Officer seat. A larger
compartment for general population inmates is located behind the Restrictive Housing
compartment. To access the general population compartment, inmates must pass through the
restrictive housing compartment.
At 11:11 a.m. the bus departed the Hughes Unit on route to the Estelle Unit near Huntsville,
Texas. On board were two Transportation CO’s. TCO Smith served as the driver while TCO
Brinegar was the rear compartment officer. Per policy, both were issued firearms that were on
their duty belts.
PAGE 26
The available video for CGL’s review ceases at this point as at that time, TDCJ did not have
any video capabilities on their transport buses. They have since begun piloting adding video
equipment on buses. The description of further events in this narrative is based on interviews
and review of TDCJ documents.
Lopez Escape: TDCJ interviews with other inmates on the transport bus indicated that Lopez
had given indications while on the bus that he might be escaping and asked if they were
“ready to rock and roll.” TDCJ reports that upon departing the facility, Lopez showed two
long metal weapons with string tied to them and what resembled a handcuff key in his mouth.
Other inmates reported that Lopez was asking them how long their sentences were and if they
wanted to escape with him. Inmate (# ) initially expressed
interest, but this changed when he realized Lopez planned to kill the transport officer, then
hijack a car and kill the driver.
Once the transport left the Hughes Unit, it was reported the noise level increased as several
inmates began “instigating a loud rapping noise, banging” while blocking the view of rear
compartment CTO Brinegar. Witnesses reported that Lopez quickly was able to remove his
restraints and that the cuff protector placed over them did not obscure access to the hand
restraint keyhole. Inmate witnesses further indicated that once out of the handcuffs, it took

PAGE 27
Lopez approximately 90 minutes to break through the bottom of the restrictive housing
compartment door using the 2 metal weapons. These metal items have never been
recovered.
Other interviews of inmates found it was common not to be properly searched for transport
and that they often are provided advanced notice of transports by medical staff.
At 1:15 p.m. the transport bus was

traveling east on State Highway 7
and between four and six miles
outside of Centerville, when TCO
Smith (the driver) felt a tug on his
handgun. He looked down to see
Lopez coming through the bottom of
the restrictive housing compartment
door. In interviews TCO Smith
reported he responded by covering
his handgun and attempted to stop
the bus by actuating the air brake.
This immediate stop pushed Lopez
further into the drivers compartment
of the bus and a struggle ensued
between the inmate and TCO Smith.
During the struggle Lopez continued
to try to access CTO Smith’s
handgun and both fell into the
stairwell area causing the bus doors
to open and both to fall on the
pavement. Lopez began stabbing
CTO Smith with what was reportedly
an 8-10 inch metal weapon. At that point, Lopez pressed the quick disconnect on CTO
Smith’s holster and gained control of the handgun from Smith’s duty belt.

PAGE 28
CTO Brinegar, seated in the

officer’s chair in the rear
compartment, initially assumed
the bus stopped due to an
accident. He exited through the
bus’s back door with a 12-
guage shotgun. He observed
CTO Smith struggling with
Lopez and reported he yelled at
Lopez to stop at which time
Lopez jumped up and reentered
the bus. CTO Brinegar
proceeded to CTO Smith’s
location and helped him up
and Smith indicated Lopez was
trying to escape and had
possession of his handgun.
Brinegar drew his own handgun
and instructed Lopez to stop, or
he would shoot. Lopez placed
the bus in forward gear. At this
point Brinegar discharged his
handgun 2 times at the bus.
Lopez had possession of CTO Smith handgun but apparently was unable to remove it from its
holster. He pointed the holstered handgun at TCO Brinegar however did not fire the weapon.
Brinegar stepped out of the probable line of fire, then fired 2 additional rounds through the
right passenger compartment window. Lopez began to drive away as CTO Smith took the
shotgun from Brinegar and yelled for Lopez to stop. Smith fired one round, blowing out the
right rear tire. Lopez continued to drive east on State Highway 7 toward Centerville.
CGL’s inspection of the bus after the incident found shattered glass on the passenger side
and a bullet hole through the front window.

PAGE 29
A brief time after the incident Sean O’Reilly, Chief of Police for the City of Jewett arrived on
the scene and was informed by CTO Smith of the incident. Chief O’Reilly then pursued the
bus, while Smith and Brinegar proceeded on foot, A civilian passing by stopped and asked
CTO Smith if they were with the bus that had wrecked near Centerville. The civilian drove
Smith to that location where law enforcement officers were already on scene where the bus
was located. Smith retrieved the TDCJ cellular phone from the bus and notified the Central
Transportation Unit of the escape. Upon inspection of the bus, Lopez was not present, and
the handgun Lopez had removed from CTO Smith’s belt was in the driver compartment of the
bus still in its holster.
TDCJ initiated its escape plan.
Over the next several weeks, efforts were made by law enforcement and TDCJ to track and
capture inmate Lopez. On May 31, 2022, 19 days after the escape, law enforcement was
informed of a burglary of a property in the area where Lopez escaped. Fingerprints were
taken from the scene along with DNA samples. On June 2, 2022, the samples were positively
matched with inmate Lopez. On the same day, law enforcement was notified by an individual
who had grown concerned after not hearing back from a relative in the area. Law
enforcement responded to the residence and found the bodies of five individuals (2 adult
males and 3 minor children). A 1999 white Chevrolet Silverado pickup was discovered
missing and a “Be on the Lookout” was issued to law enforcement agencies statewide.
A short while later law enforcement deputies in Atascosa County identified the missing pickup
and followed it. The vehicle was disabled using spike strips. Gunfire broke out between
Inmate Lopez and the deputies, ending with inmate Lopez being shot and killed.
TDCJ’s own internal review found additional failures in practices/policy compliance by staff
including:
• Lack of Supervision. Custody supervisors were not appropriately monitoring staff or
making their required supervisory rounds through the facility.

PAGE 30
• Falsification of Documents. Certain staff were found to have falsified documents

regarding cell searches, or security rounds performed.
• Advanced Notice of Transports. Inmates interviewed reported it is not uncommon for
UTMB staff to provide them advanced notice of upcoming medical
appointments/transports.
• Other Search Issues: A small home-made tool kit was found in the Lopez’s boot
raising concern for both the search procedures and the allowance if inmates to wear
their personal boots and shoes on transport.
The serious consequences of this escape cannot be understated. Five citizens lost their lives at
the hands of inmate Lopez. Correctional Officer Randy Smith was attacked and stabbed
multiple times by Lopez. CO Smith fortunately was treated and released from the hospital.

PAGE 31
Chapter 5: Evaluation of Policies/Training Practices

As part of the escape review, CGL sought to evaluate both the agency-wide training
requirements for custody staff, and the individual training provided to those staff that were
involved in the preparation/transport of inmate Lopez.
TDCJ Training Requirements

TDCJ’s statewide training plan is issued in the FY 2022 Correctional Training Department
Training Plan dated September 1, 2021. This comprehensive plan outlines the training goals,
training requirements, and curriculums for all levels of staff. TDCJ’s training plan for custody
staff is consistent with American Correctional Association (ACA) standards.
The training plan defines three components of training for newly hired uniformed correctional
staff:
• Phase I. Pre-Service Academy Training. All newly hired staff in correctional positions
must attend TDCJ’s Pre-Service Training Academy and complete a physical agility test
prior to completing the academy.
• Phase II. On-the Job Training (OJT). Phase II OJT is designed to bridge the employee
between pre-service training and their unit-specific work environment.
• Phase III. Shift Assignment/Mentoring. In Phase III staff are assigned to a post with a
mentor who provides direct supervision. Both the mentor and the Phase III trainee are
assigned to the same post.
Phase I. Phase I consists of 240 hours of training. All newly hired correctional officers are
required to successfully complete this training. It should be noted that TDCJ Training and
Leadership Development Division Corrections Training Department has received 100 percent
ACA accreditation since 2005. The major modules covered in Phase I training are:
• Agency Overview
• Employee Professionalism
• Unit Tour of Duty Posts
• Inmate Rights
• Safe Prisons
• Report Writing/Disciplinary Procedures
• Restraint and Escort Procedures
• Legal Responsibilities
• Incident Management
• Communication with Peers
• Go Home to Your Family – How to maintain safe environment and avoid
mishaps/injury.
• Mental Health
• Communication
• Understanding Inmate
• Security Concerns
• Risk Management
• Chemical Agents/Exposure
PAGE 32
• First Aid/CPR
• Hostage Situations
• Officer Post Orders/Duties
• Firearms/Perimeter Security
• Physical Agility Test
• Physical Training
• Owning Your Wellness
TDCJ’s On-The-Job Training (OJT) Program Procedures Guide issued November 2019
serves as a detailed guide for OJT training for new custody staff. This guide delineates the
mandatory OJT program and outlines procedures to implement Phase II and Phase III
training.
Phase II. The goal of Phase II is to begin to apply what was learned during Phase I pre-service
training to an actual work environment. As a result, Phase II training occurs at a correctional
facility. In Phase II correctional staff complete the following training segments:
• Segment 1. Basic Unit Operations Training: (minimum of 24 hours) Trainer reinforces
policies and procedures as they apply to basic operations of a unit.
• Segment 2. Observation of Housing or Specific Specialty Housing Training (minimum
of 24 hours). OJT trainees observe practices and operations of housing units.
• Segment 3. Shadowing Mentor (minimum of 48 hours) Each OJT trainee is assigned
a mentor on post and mentor provides guidance and direction.
• Segment 4. Practical Application Competency Skills (minimum of 8 hours) Field
Training Officer evaluates OJT trainee on their competencies and abilities to
practically apply job-related skills.
At the completion of Phase II, a correctional major is required to conduct an interview with
the officer and assign them to a shift and post.
The On-The Job (OJT) Program Procedures Guide also denotes what competencies the OJT
trainee should exhibit as part of the Segment 1 training, and these competency requirements
are listed in extensive detail. Many of the competency requirements in Phase II provided clear
understandings of security procedures that Hughes Unit and transportation staff failed at
when preparing inmate Lopez for transport. We can therefore assume that all custody staff
have received training in these proper procedures during Phase II. The relevant requirements
include:
• Cuff Protectors. Procedures for applying the hand restraint protector (cuff protector or
black box) indicate “When the protector is closed around the hand restraint housing
and chain, the keyhole should not be exposed in any way.”
• Leg Restraints. “A leg restraint should not be placed on any part of an offender’s
footwear or pant leg.”
• Strip Searches & Restrictive Housing: The strip search competencies are thoroughly
described, and the Restrictive Housing Escort notes fundamental requirements for
those in Restrictive Housing status:

PAGE 33
o Requires inmate be strip searched “every time they are escorted from their
assigned cell.”
o It also notes staff should “Never turn away or look off while the offender is
redressing (after a strip search) because they could easily hide contraband in their
mouth or in the already inspected clothing.”
o It also requires a restrictive housing inmate be “in hand restraints anytime they are
escorted from an assigned cell.” Additionally, these restraints should be placed on
the inmate “through the food slot” in the door.
Phase III. Phase III is a shift assignment/mentoring program that typically begins upon
completion of Phase II training. It also consists of a minimum of 40 hours of training where
an assigned mentor guides and advises the employee while observing their performance. On
the roster, the trainee and the mentor are assigned to the same post. Phase III is provided by
the local institution.
In-Service Training. Annual In-Service Training requires 40 hours annually which is offered at
six regional training academies and 32 unit based sites. This training is also consistent with
ACA requirements. The modules covered in In-Service Training are as follows:
• Pre-Test
• Physical Training (30 min/day except PAT day) Peer Communication
• Core Values and Ethics
• Crisis Intervention Training
• Mental Health First Aid/Suicide Prevention and Response
• Employee Survival and Use of Force
• Offender Management: Special Populations
• Owning Your Wellness
• Observing, Assessing, Reporting Behaviors
o Defensive Tactics
o Firearms, Range/Unit Safety, Chemical Agents
o Incident Command System and Emergency Procedures Infection Control, First
o Aid/Medical Emergency and CPR/AED Orientation and Testing Standards
• Physical Agility Test
• Safe Prisons/PREA Program
• Security Issues
• Security Issues Practical Application: Restraints, Pat Search
• Go Home to Your Family
• Discretionary Block
• Testing Standards/Post Test/Critiques
The “Offender Management: Special Populations” component of the in-service training

addresses needs/behaviors when supervising those in Restrictive Housing. How to properly
conduct a strip search is part of pre-service training, but not formally included in annual
training. We note that TDCJ recently revised their strip search “how to” video and required all
staff who may conduct strip searches verify review of the video. The CGL team reviewed this
video and found it was comprehensive and easy-to-understand.

PAGE 34
Also outlined in the Training Plan are training requirements for specific post assignments
within the TDCJ system, such as Transportation Officer, administrative segregation, etc.
Transportation Unit Additional Training. The Transportation Unit has its own additional OJT
training requirements for new staff in the Unit. This requires 40 hours of classroom training
that includes weapons training and defensive driving followed by 4 weeks of shadowing with
a mentor. No annual transportation-specific retraining is required for transport staff; however,
transportation staff do participate in the agency’s annual in-service training as well as
completing annual firearms qualification and a tactical firearm course.
Individual Staff Training Review. CGL reviewed training records of those staff assigned to the
Lopez transportation bus and those who had some role in the preparation of Lopez for the
transport.
Transportation Staff. Two staff were responsible for the transport of inmate Lopez. Their
training appears to be current.
Transportation Correctional Officer IV Jimmie Brinegar;

• Completed Phases I, II, and III training between 7-27-2007 to 8-24-2007.
• Last annual training received on 9-16-2021
• Offender Transportation Training Program received between 9-11-2017 to 10-20-
2017.
• Last weapons qualification appears to be 9-16-2021 during annual training.
• Texas class B driver’s License is valid until 8-08-2030.
Transportation Correctional Officer IV Randy Smith;

• Records provided do not include information regarding Phase I, II and III training.
• Last annual training received on 12-16-2021
• Offender Transportation Training Program between 11-3-2014 to 12-17-2014.
• Last weapons qualification appears to be 12-16-2021 during annual training.
• Texas class B driver’s License is valid until 7-14-2028.
Other Staff. Several other staff were either involved in the preparation of Lopez for transport
or were found to have violated agency policy in TDCJ’s review of the escape. It should be
noted that COVID and staff shortages appear to have negatively impacted TDCJ’s ability to
provide annual in-service training to all employees. Documentation provided for 22 staff
(including the two transportation staff) found that 6 had not received annual training since
2020. These records also show that all 6 of these staff had been rescheduled for annual
training, but 2 of those were listed as “No Show” for the rescheduled dates (Exhibit 15). We
cannot verify whether the other 4 had attended their training as the rescheduled date was
after the time of our records review.
Post Orders. CGL reviewed post orders that provide the responsibilities of staff assigned to
each post. While most are very detailed, we found that many had not been reviewed in

PAGE 35
several years. ACA standard 4-ALDF-2A-04 indicates that post orders be reviewed annually
and updated as needed. TDCJ acknowledged that during the COVID pandemic, policy/post
order review functions were halted to redeploy staff to critical needs. Also, their recent internal
review of the Security Manual Policy in February 2022 found that 89 of 90 post orders need
revised while the other nine were under revision.
Exhibit 15: Staff Training Documentation
Last Annual Next Scheduled

Phase II & In-Service In-Service
Employee Position Phase I III Training Training
White, Aaron Correctional Officer V 10/18/11 09/19/17 10/21/21
Guishard, Correctional Officer IV 10/16/20 11/23/20 06/10/22
Bernard
Stewart, Brantley Correctional Officer II 02/18/22 03/25/22 -
Lawson, Damion Correctional Officer IV 11/16/18 01/21/18 11/12/21
Miller, Dillon Correctional Officer II 5/13/22 06/16/22 05/25/22
Defreitas, Gerald Correctional Officer V 02/12/10 09/02/15 03/11/22
Velasquez, Correctional Officer IV 04/20/18 06/27/18 04/12/19 07/29/22 No
Gerardo, Show
Haws Jr., Harvey Lieutenant 01/15/09 02/17/09 02/18/22
Brinegar, Jimmie Correctional Officer V 07/27/07 08/24/07 09/16/21
Watson, Joshua Sergeant 02/10/12 09/19/17 04/22/22
Jones, Karl 06/12/17 03/27/18 07/05/19 07/08/22 No
Show
Sharp, Kristopher Sergeant 01/15/07 03/07/08 04/22/22
Thomas, Mark 08/11/17 09/25/17 07/15/22
McElhaney, Correctional Officer IV 04/02/21 05/29/21 -
Michael
Akinsiku, Correctional Officer II 04/08/22 09/19/22 -
Morakinyo
Walton, Nicholas Correctional Officer IV 01/18/19 02/22/19 01/10/20 01/05/23
Taylor, Pamela 02/03/97 07/29/97 10/14/19 09/09/22
Smith, Randall Correctional Officer IV 02/12/21 04/01/21 04/01/21
Martin, Shane Captain 05/02/14 07/21/16 05/17/19 07/15/2022
Miller, Tanya Correctional Officer IV 01/18/19 03/19/19 12/10/22
Hocutt, Treyvon Major 02/09/09 02/10/09 03/22/19 09/09/2022
Smith, Randy Correctional Officer V 02/16/21
*Highlighted reflect those who are past due on annual in-service training.

PAGE 36
Chapter 6: TDCJ Corrective Actions

In reaction to the escape and findings from its own internal investigation, TDCJ has made a
substantial number of improvements to past practices and policies that may have contributed
to inmate Lopez’s ability to escape. The agency ordered a Serious Incident Review that clearly
identified staff security failures throughout the preparation and transport of Lopez.
Additionally, in early June 2022, TDCJ took the unconventional step of suspending inmate
transports for a week so that it could dedicate its limited resources to reviewing transportation
practices. During this shutdown, TDCJ found several issues that could have contributed to
security issues during transport. The following represent the major policy and practice
changes implemented by TDCJ since the escape. These changes were issued across the
organization by a variety of methods (emails, policy changes, meetings, etc.)
• Transport Staffing. TDCJ increased to three (3) the required number of security staff on
every transport. If 3 staff cannot be provided for the transport, the transport will not
occur. This direction was issued in a June 10, 2022, agency meeting. Changes
include:
o Bus Transports now require 3 staff in the vehicle.
o Van Transports will now require 3 staff in a van. Two officers will be armed, and
the 3rd will be unarmed. If there is not enough room for a 3rd officer in the van,
they will follow in a chase vehicle. If the 3rd officer is following in a chase vehicle,
they will be armed.
o The mobile correctional officer team and correctional officers from correctional
facilities will continue to augment transport staffing until transportation staffing
levels are sufficient.
o Clarified that if an inmate becomes disruptive during transport, the transport
should be diverted to the nearest facility or county jail. The disruptive inmate will
be removed from the vehicle with the aid of staff and/or law enforcement. Also,
the nearest facility will respond and remove the inmate from the transport.
• Transport Vehicle Video Surveillance. TDCJ has begun piloting the implementation of
video surveillance systems in transport buses. To date, four buses have been outfitted
and these systems place cameras within the buses and allow for transport staff on the
bus to more clearly monitor inmates held in secure portions of the vehicle.
Additionally, transportation headquarters staff can remotely view these cameras while
a transport is occurring. TDCJ indicated all transport vehicles will be outfitted with a
video surveillance system.
• Expand Inmate Transportation Supervision. Supervision of transport practices has been

expanded to require:
o Supervisors are now required to review surveillance videos of officers conducting
their duties on units and Transportation supervisors are required to inspect and

PAGE 37
evaluate transport staff searches, restraint procedures, identification of inmates,

etc.
o Supervisors will review and monitor live video from video surveillance systems
being installed in transport vehicles.
o Inmate Transportation supervisors will regularly evaluate officers conducting
inmate searches, applying restraints, identifying inmates, loading, and unloading
transport vehicles and on-road transport practices.
• Improve Understanding of Strip Search Requirements. In response to the multiple

failures in the strip searches of inmate Lopez, the agency has developed a revised
training video that more clearly explains and demonstrates the requirements of a
proper strip search. This video was issued to all supervisors in a June 22, 2022, email
and any applicable staff who conduct strip searches were required to verify they
viewed the video by July 20, 2022. All of those completed the training at this time,
except for those out on leave.
• Expanded Search Requirements for Transport Inmates. New search requirements were
issued:
o Use of Body Orifice Security Scanner (BOSS chair) for all transports. Previously
only restrictive housing inmates were required to be scanned by the BOSS chair
prior to transport. In light of the failure to use the BOSS chair in the Lopez transfer,
this was reinforced, but was expanded to be required for all inmates, including
those in general population. If a BOSS chair is not available, the inmate will be
searched with a handheld metal detector or a ferrous metal detector. If no
equipment is available to screen the individual, the Inmate Transportation Hub
officer will call the transportation hub supervisor for direction on whether to
proceed with the transport. (June 10, 2022, inter-agency meeting)
• Change In Transport Clothing/Property Requirements.

o To reduce their ability to hide contraband, male restrictive housing inmates exiting
their cell for transport, are only to be in boxers and shower shoes (“slide-on
shoes”). Female restrictive housing inmates will be issued a gown when strip
searched. (June 10, 2022, inter-agency meeting)
o Restrictive housing inmates are no longer allowed to have boots in their possession
given the ability to hide contraband in them. This change was issued on June 15,
2022 and will be reflected in updated Restrictive Housing Plan and Administrative
Directives.
o Inmates to be transported (including those in general population) will not be
allowed to wear any personal clothing on transport. They are required to change
into newly issued clothing after being strip searched and prior to boarding the
transport vehicles.
o All restrictive housing inmates will be transported in orange jumpsuits, boxers,
socks, and slide-on shoes. These jumpsuits have been deployed and are in use.
o General population inmates will receive a new set of clothing after being searched
and prior to transport.
PAGE 38
o Inmates will be limited to one (1) bag of property for transport. Property is stored in
the under-storage space or other space on the bus that is inaccessible to inmates.
Property will be stored outside the occupied inmate cage during van transports.
• Hand Restraints/Cuff Restraint Protector.

The internal review after the escape
revealed that some cuff protectors (black
box) did not fully cover the keyholes in the
hand restraints which may have allowed
inmate Lopez to manipulate the locking
mechanism. At the time of the escape,
Inmate Transportation policy 03.05
outlined the procedure for applying the
cuff protectors but did not require they be
inspected to ensure they cover the keyhole in the hand restraints. The following
changes were made regarding use of cuff restraint protectors and the inspection of
those items.
o On June 1, 2022, a security bulletin was issued that:
§ Directed an inspection of all cuff protectors.
§ Required a security supervisor check restraints prior to loading inmates on
transport vehicles and ensure that the hand restraint keyholes are not exposed
after the cuff protector is applied. This was also added to transport post orders.
Inmate Transportation staff are requiring Inmate Transportation Hub
supervisors and unit supervisors to print and sign their name on the back of the
inmate transportation Driver’s Vehicle Inspection Report (TN-28) indicating they
checked restraints.
o It was found that some additional cuff protectors were insufficient in covering the
hand restraint keyhole. These were removed from service.
o To further reduce inmates’ ability to act alone, all general population inmates are
paired and restrained by hand, restraining two inmates, side by side, with one
hand restraint. Odd number inmates are restrained by themselves with hand
restraints only.
o Restrictive Housing inmates are restrained with hand restraints, cuff protector, leg
restraints, pad lock and connecting chain. Each inmate of this custody is restrained
individually.
o Reinforced that leg irons (leg restraints) are to be placed on skin and not over the
pantleg or boot-top of individual, thus ensuring a more secure application. This
was added to the transportation officer post orders as well.
• Enhance Vehicle Security Package. The physical security of the interior of transport
buses is being improved.
o Plexiglas: Buses have been inspected to ensure visibility through the Plexiglas
partitions (much of the Plexiglas inside the transport bus used in the escape was
scratched and obstructed clear view of different areas of the bus). Where needed,
Plexiglas is being replaced.
PAGE 39
o Reinforcement Bars: Metal bars in security doors and screens are being added to
reduce the size of the unreinforced expanded metal areas that Lopez was able to
cut through.
o Removed mail from transport vehicles: Existing policy allowed for institutional mail
to be transported in the vehicle. This can obstruct line-of-sight. Mail will no longer
be transported in the transport vehicle.
• Holster Requirements. Prior to the escape, transport officers were allowed to wear
quick-disconnect holsters for their weapons. This could allow for an inmate to easily
remove an officers’ handgun. The quick connect/disconnect holster will be replaced
with holsters that are not detachable from the belt. (June 10, 2022, inter-agency
meeting)
• Reducing Transports. TDCJ transports over an average of 1,300 inmates per day.
Efforts are being made to evaluate options to reduce transports. In the area of medical
services, more on-site services, and telemedicine options are being explored with
UTMB.
• Established High-Risk Inmate Categories. On June 23, 2022, TDCJ’s Classification

and Records department issued an email outlining two additional high risk inmate
categories added to the offender management system:
o Security Risk Transfer (SRTF) Inmates who meet all four of the following statuses
must be transported alone in a van with 3 officers:
§ Housed in restrictive housing
§ 20+ year sentence length
§ Committed on violent offense
§ Is assigned a Security Precautions Designation per existing Administrative
Directive AD.04.11
o Capital Murder Offenses: The agency created a code so they can be easily
identified. Inmates with a capital murder offense code can ride on normal
transport, according to their custody and will only be transported alone if they
meet other requirements (SRTF, high profile, etc.)
• Visitation Cancellation. In a June 17, 2022, email, to ensure proper staffing levels for
transports, Senior Wardens were provided the full authority to cancel their in-person or
video visitation based on staffing levels and security needs.
• Other TDCJ Changes. TDCJ also made several other changes to policy and officer
post orders to enhance security of transports. These included changes to the weapons
custody staff carry on transport, their pre-transport inspection requirements, and
requirements while in-transport.

PAGE 40
Staff Disciplinary Actions: As a result of its own internal investigation, TDCJ initiated
disciplinary action against more than 20 staff and supervisors whose performance failed to
comply with TDCJ policy.

PAGE 41
Chapter 7: CGL Recommendations

Staffing Shortages. Our review found that TDCJ’s staff shortages are at critical levels,
especially in the correctional officer ranks. This is clearly shown in the Hughes Unit
Turnout Rosters for the day of the escape where only a small portion of the Priority 1
Positions at the facility could be filled with the limited staff available. The few staff
available carried a heavier workload and were working increased levels overtime.
These shortages led to a security environment that better allowed Lopez to escape.
Security Lapses. While these staffing shortages, especially at the Hughes Unit, may
have been a factor in inmate Lopez’s ability to escape, they are not an excuse for the
multitude of security lapses that occurred in preparing Lopez for transport. TDCJ, like
most correctional systems, builds multiple redundancies into their practices to ensure
that one single failure cannot have catastrophic results. History shows that when
serious incidents of this type occur in a correctional setting, it is not a single failure
that leads to the incident, but the compilation of multiple failures. That was the case
with the Lopez escape. The combination of several inadequate strip searches, failure
to search property, poorly applied restraints, and failure to use the BOSS chair
improved Lopez’s odds for a successful escape. The fact is that if one of these actions
was followed in compliance with existing policy, it is likely that the escape would have
been thwarted. For example, the escape could have likely been prevented if staff
would have scanned Lopez in the BOSS chair prior to transport, a task that would
have added less than a minute onto the process.
Lapses Appear Endemic. TDCJ’s internal review as well as our independent

assessment found that staff at the Hughes Unit had become complacent, and
circumvented security procedures in favor of hastily completing responsibilities. Given
TDCJ’s internal investigation as well as the number of failures during this single
transport preparation, these breakdowns appear to have become routine at the
Hughes Unit and a matter of regular practice rather than isolated incidents. Although
we did not investigate practices at other TDCJ Units, it is possible that the
complacency regarding security practices is occurring there also.
Lack of Supervisory Oversight. Supervisory oversight is key to ensuring staff

compliance and preventing staff complacency. However, as noted in TDCJ’s Serious
Incident Review, supervisory security staff had not been conducting regular inspections
or routine rounds. Additionally, we found there is no policy that identifies when/where
facility leadership are to conduct rounds and the frequency of those rounds. Also,
surveillance systems can improve oversight, and the Hughes Unit has a significant
number of remote surveillance cameras. But the ability to review what is captured on

PAGE 42
these camaras is difficult and makes supervisory staff’s ability to remotely observe staff
compliance more time-consuming.
CGL agrees with the corrective steps taken by TDCJ noted in the earlier chapter, however,
additional actions are needed.
One particular challenge exists when providing additional recommendations. Correctional

systems are very good at conducting post-incident reviews after a serious incident. The
corrective actions that result from post incident reviews often add responsibilities to staff post
orders. However, in times of severe staff shortages, those additional responsibilities may not
be achievable. Therefore, our recommendations are cognizant of the need to provide long-
lasting solutions that do not further overload staff.
The following represent CGL’s additional recommendations:
1. Continue to Develop Strategies to Reduce Vacancies/Address Staff

Recruitment/Retention. Although this review was not a staffing assessment, it was
clear that severe staffing shortages have impacted staff and facility performance.
Asking employees to do more with less is difficult during this shortage and can result
in further retention issues. TDCJ and the legislature have recently increased line staff
salaries to stem the loss of employees, and TDCJ has implemented other practices to
reduce hiring lag and expand their recruiting base. CGL recommends TDCJ continue
efforts to improve staff retention.
2. Focus Upcoming Security Assessments on Searches and Transports. TDCJ’s internal

security assessment process paused during the pandemic and is being restarted. This
compliance monitoring should initially focus on basic security practices and
transportation security.
3. Review all Medical Transports with UTMB for Appropriateness. TDCJ has already
begun to reduce transports through increased telemedicine and providing more on-
site services. As stated in discussions with the UTMB Medical Director, the existing
telemedicine equipment is outdated and needs to be upgraded to the current
standard. Upgrading equipment would allow for enhanced telemedicine usage as the
quality of telemedicine services are increased. This would result in the need for fewer
medical transports. To go further TDCJ should consider assembling the past year’s
inmate transport data to show the why, when, how, and where of each transport. In
the case of medical transports, the data could be analyzed in conjunction with UTMB
to determine alternatives to transporting the inmate.
4. Reorganize/Streamline TDCJ’s Policy Structure. We found the policy structure within

TDCJ to be overly complex and decentralized. Formal policies serve multiple
purposes for an organization. Most importantly, they act as a uniform rule book for
staff conduct and performance. By delineating expected standards, policies help

PAGE 43
establish consistency across staff and better ensure compliance with expectations.
Staff should be able to quickly find a policy and then understand its requirements.
Within TDCJ, however, just finding a policy requirement is complicated given there
are a number of different sources. CGL requested clarification regarding the policy
structure and policy sources in TDCJ and was provided with the following delineation:
o Department Policy Operations Manual (DPOM) is TDCJ’s manual that contains

all board policies, executive directives, (excluding personnel directives),
administrative directive and board rules.
§ Board Policies are approved by the Texas Board of Criminal Justice

(TBCJ) under the coordination of the Office of the General Counsel and
signed by the TBCJ chairman. These policies reflect the intent of the
TBCJ regarding the internal management or organization of the TDCJ
and do not affect private rights and procedures.
§ Executive Directives are statements of the executive director’s principles,

philosophy, and executive intent regarding the executive director’s duty
to administer and enforce laws relating to the TDCJ and responsibilities
as designated by the TBCJ. These directives grant authority to the
appropriate designee to implement a procedural directive as required
and are signed by the Executive Director.
§ Administrative Directives may apply to more than one division and are
signed by the Executive Director. These directives are more procedural
than executive directives.
§ Board Rules are statements of general applicability that prescribe,

establish, or interpret policy or describe the procedure or practice
requirements of the TDCJ, and generally affect people or entities
outside the TDCJ. These rules are approved by the TBCJ.
o Personnel Directives are executive directives that establish procedures

regarding human resources issues, are contained in the TDCJ Personnel
Manual, and are signed by the executive director. The Human Resources
Division is the proponent for all personnel directives.
o The Corrections Institutions Division (CID) Security Manual is a four-volume set

of manuals containing operational plans, post orders, security memorandums,
and emergency procedures relating to correctional staff and security operations
at units, including contract facilities.
§ Operational Plans are guidelines designed to provide uniform rules

defining organizational and administrative requirements related to a

PAGE 44
specific operation.
§ Post Order (PO) is a policy documenting specific job duties and

responsibilities for posted security positions. POs shall provide guidance
for correctional officers in performing their job functions.
§ Security Memorandums are policies outlining operational and security

procedures for all TDCJ units to ensure correctional staff consistently
perform essential functions, such as armory operations.
§ Emergency Procedures are pre-determined plans to manage an

emergency. Emergency procedures are implemented during times other
than normal operations, with the intent to return a unit to normal
operations.
o The Correctional Managed Health Care policies are developed in accordance

with procedures implemented by the Joint Health Services Policy and Procedure
Committee and are approved by the respective university medical directors.
o Division Directives establish procedures that apply to individual divisions and

may be referred to as department policies. Each division is responsible for its
own internal review process, maintenance, and distribution. Divisions may have
more detailed department or division operational manuals or standard
operating procedures manuals.
Additionally, we were provided procedures from a separate Security Operations

Procedure Manual and several Operational Plans including a Restrictive Housing Plan,
Incident Management Plan and others that set policy requirements.
As a result of this complex structure, it is extremely difficult to locate a policy

requirement, which we experienced to be true in this escape review. For example,
early in the project we sought to find the policy governing the number of staff required
per transport. We had been informed that in prior years, TDCJ required three staff per
transport, but this changed to two per transport several years ago. We wanted to
understand specifically what the agency policy required, and by whose authority the
reduction in staff per transport was approved. In most correctional systems, the
number of staff required per transport is a critically important policy decision and
therefore, would require agency leadership approval to change. We looked through
several sources including TDCJ’s Administrative Directives, Transportation Unit
Standard Operating Procedures, Security Operations Procedures and Security
Memorandums, all with no success. Finally, we noticed the requirement while
reviewing the Transport Officer Post Order. Post Orders are an unusual location for a
major requirement of this type. A Post Order is intended to list the duties and
responsibilities of staff assigned to a specific post. The number of staff required per
transport is not a post responsibility, but rather, is administrative guidance. It is a
PAGE 45
responsibility of someone other than the Transport Officer to ensure the appropriate
number of staff per transport.
Additionally, because this requirement is in a Post Order, it can be changed without

the Executive Director’s approval. In this case the post order was issued in 2018 under
the authority of a past Director of the Correctional Institutions Division.
TDCJ should engage a study to improve their policy structure that achieves the
following:
o Streamlines the policy structure.

o Improves the clarity of policy requirements.
o Elevates those important requirements to the agency level that requires any
policy deviation be approved by the Executive Director/Designee.
o Ensure post orders are annually reviewed and up to date.
5. Revise the Security Precaution Designator Policy. The Security Precaution Designator
policy should be revised to establish more detail regarding transport requirements for
those inmates with a past history of escapes or other factors or circumstances that may
indicated an individual has a higher risk of escape. Currently the policy prescribes only
very limited transport implications for inmates with a recent escape. This revision
should be consistent with any changes made to the Security Risk Transfer or High-
Profile designations.
6. Pilot Policy Requirement Modifications that Consider Current Staff Shortages.

Correctional officer staffing levels are very low in TDCJ, and this has created an
environment where the limited remaining staff are attempting to perform the policy
requirements of multiple positions. The honest question to be asked is “Are these
policy requirements impossible to achieve given the current staffing crisis.” This
appears to be the case, and we clearly found a large number of staff take security
shortcuts to get the work done. Rather than continuing to ask staff to do the
impossible, which in reality means staff continuing to make shortcuts, another option is
to right-size policy requirements to be consistent with the current staffing reality. So as
an example, instead of unreasonably requiring 10 cell searches be conducted by a
correctional officer, only 5 would be required. The benefit could be that 10 poorly
conducted cell searches would be replaced with 5 that were appropriately conducted.
TDCJ should consider piloting the reduction of some of these requirements to a more
achievable level during the current staffing shortage.
7. Reinforce Policy Concerning the Prior Notice of Transports. The Executive Director
should issue an order reinforcing that inmates are not to be given advanced notice of
the dates/times of future transports. This should be provided to all employees and
contractors. Correctional Managed Health Care Policy E-42-1 should also be
modified to include similar language.

PAGE 46
8. Establish a Duty Warden Inspection Schedule. Establish a duty warden policy that
requires administrative rounds at each facility. This policy should define the frequency
at which facility administrative staff (wardens, assistant wardens, majors) should
personally visit and conduct scheduled and unscheduled inspections of the facility. The
frequency for these inspections should depend on whether the space is an “inmate
activity area” (housing units, kitchens/dining, health care units, recreational areas,
educational, vocation, maintenance, and industry buildings) or non-activity area
(towers, perimeter security administration building, warehouses, commissary, etc.)
Inmate activity areas should require more frequent inspections. These inspections also
should be documented.
9. Require Documented Regional Director Inspections. TDCJ should establish a policy

that requires regional directors make a minimum number of visits to the units under
their authority. Additionally, policy should require that regional directors and staff
conduct periodic formal inspections of their unit each quarter, unless a security audit is
being conducted that quarter. These formal inspections should focus on vulnerability
and policy compliance and use an instrument that can be regularly adjusted to meet
the primary concerns of agency leadership.
10. Conduct Desk Audit of Warden’s Position. It was reported that many supplementary
administrative responsibilities have been added to the warden position in TDCJ over
the years. It appears these duties have result in facility managers having less time to
spend inside their facilities to observe inmate activities and staff practices. Based on
this audit, TDCJ should make any changes necessary to maximize a warden’s ability to
be present in the key areas of their facility to observe inmate and staff morale,
operations, and security practices.
11. Consider Reconfiguring Transport Buses to Improve Bus Security. We recommend

TDCJ implement one or both of the following changes to their configuration:
• Turn 3rd Officer Seat to Face Inmate Compartments. The current 3rd officer seat
faces forward, directing the officer’s vision away from the inmate compartments.
• Relocate the Restrictive Housing Compartment to the Back of the Bus. The current
bus configuration places general population inmates at the back of the bus, with
restrictive housing at the front. We recommend TDCJ consider reversing this,
placing the less controlled population (general population) in the front, and the
more controlled at the back, in closer proximity to the rear compartment officer
and further away from the driver.
12. Require Random Review of Strip Searches for Policy Compliance. Failure to
adequately perform a strip search was a major contributor to Lopez’s escape. Random
video reviews of strip searches will provide TDCJ with a better understanding of staff
compliance with this important policy. Findings should be reported to the facility

PAGE 47
administrator. Implementing this recommendation will be difficult given current

practices in the facilities due to two reasons:
o Limited Video Review Staff. Facilities have one video surveillance sergeant and
an assistant to monitor and review video footage. There are over 1,000
cameras installed at the Hughes Unit making comprehensive monitoring
impossible. Other states have addressed this issue using volunteers. These
volunteers often include past agency staff who have retired in honorable
conditions or retired law enforcement personnel. The volunteers could be
trained by the Surveillance Sergeant and observe real-time searches, looking
for policy violations. They could make those reports of violation to the Sergeant
as they occur so corrective action could be implemented immediately.
o Documentation of Strip Search Events. Housing staff do not log when strip
searches occur resulting in the need for video surveillance staff to spend
considerable time manually scrubbing through videos to locate strip search
events. To remedy this, housing staff should document the time and location of
every strip search and that information should be provided to video
surveillance staff. This will provide a guide of where to focus video search
efforts and improve their efficiency.
13. Inspect Integrity of Every Restrictive Housing Cell in the Hughes Unit. During our tour
of inmate Lopez’s cell in the Hughes Unit we found gaps between the wall and the
plumbing chase, which could have allowed for the storage or transfer of contraband.
A documented inspection of every cell in Restrictive Housing units should be
immediately conducted.
14. Do Not Allow Inmates to Take Personal Property with Them on Bus. Any inmate
property should be limited and carried either in a chase vehicle or a secure area of
the transport vehicle that does not hinder site lines or limit the amount of property
inmates can take on a medical transport.
15. Require Supervisory Oversight (Lieutenant or Above) of Out-Processing of Any Inmate

for Transport. A lieutenant or above should be required to monitor the sallyport area
where inmates are moved to the transport bus. This area should be secure and free of
other inmates.
16. Enhance Publication Review Notification Practices: Establish a procedure requiring

reporting to facility warden/associate wardens of any book/publication ordered by or
sent to an inmate that may be detrimental to security, might facilitate criminal activity,
or that might aid in a potential escape. TDCJ’s internal review found that, prior to his
escape, inmate Lopez had ordered the following publications that could have
indicated he was planning the escape.
o U.S. Army Survival Manual – How to Manufacture Weapons

PAGE 48
o Unlocking Secrets – How to Manipulate

o Ultimate Survival Manual – How to Manufacture Weapons
o The Ninja Mind -Offensive and Defensive Fighting Techniques
o Truth Detection – Manipulation Techniques
o Mind Control – How to Manipulate.
These books were shipped to the facility and upon review by mailroom staff, were
appropriately denied. However, there is no policy requirement that facility
administration be made aware when denials of publications that could impact facility
safety and security. If this notification had been made, it is possible his security
supervision may have been increased and his method of transport altered.
17. Eliminate Multiple Security Rosters at Correctional Facilities. The existing practice of
running multiple, separate turnout rosters at each facility can result in more critical
posts being left unfilled in favor of less critical posts.
We found the multiple rosters at the Hughes Unit may have contributed to the
understaffing in restrictive housing, where inmate Lopez was housed.
The Hughes Unit operates with 3 separate and distinct security rosters (turnout rosters):
o Building Turnout Roster. The Building Turnout Roster covers security staffing for
the general population housing section of the facility as well as some support
areas. Staff assigned to the Building Turnout Roster generally work one of two
12-hour shifts (5:30 a.m. to 5:30 p.m., 5:30 p.m. to 5:30 a.m.). The Building
Turnout Roster has a listing of posts designated as either Priority 1 or Priority 2.
o Restrictive Housing Turnout Roster. The Restrictive Housing Turnout Roster

covers those posts needed in the Restrictive Housing/Mental Health housing
areas. Staff assigned to the Restrictive Housing Turnout Roster generally work
one of two 12-hour shifts (5:00 a.m. to 5:00 p.m., 5:00 p.m. to 5:00 a.m.).
The Restrictive Housing Roster also has a listing of posts designated as either
Priority 1 or Priority 2. In general, those posts on the Restrictive Housing
Turnout Roster are more complex to manage, more critical to security, and
require a higher level of staff supervision than those on the other turnout
rosters.
o Non-Shift Turnout Roster. The Non-Shift Roster are those additional posts that
are not assigned to a shift. These posts may typically provide administrative
support and/or have specialized responsibilities (e.g., kitchen supervision,
therapeutic escort team). Staff assigned may work an 8-hour, 10-hour or 12-
hour shift. The Non-Shift Turnout Roster does not have any Priority 1 posts.

PAGE 49
Each of these turnout rosters operates independently, with a shift supervisor and a
cadre of assigned staff dedicated to each. Each is responsible for finding staff in their
own cadre to fill their posts.
In times where ample staff exist, having 3 separate rosters may have provided shift
supervisors with a more manageable number of posts and staff for which they were
responsible. However, when severely short staffed, we found the 3 separate rosters
creates issues with the ability to ensure the most critical posts are filled.
The staffing imbalance this practice creates was apparent for the shifts that were
responsible for preparing inmate Lopez for transport (2nd shift May 11, and 1st shift
May12th 2022). On those shifts the Restrictive Housing Turnout Roster had a much
higher percent of Priority 1 positions left vacant than the Building Turnout Roster.
Exhibit 16 provides the comparison over these two shifts.
Exhibit 16: Turnout Roster Comparison
Restrictive Building (General

Housing Priority 1 Population) Priority
Posts 1 Posts
2nd Shift, May 11
# Not Filled or Deviated 9.5 14.5
Percent Not Filled/Deviated 40% 29%
1st Shift, May 12

# Not Filled/Dev 12.5 6
Percent Not Filled 40% 15%
On the 2nd shift on May 11, 2022, 40 percent of the Restrictive Housing Turnout
Roster Priority 1 Posts were left vacant, while 29 percent of the Building Turnout Roster
were vacant. The disparity was even greater on the 1st shift on May 12, 2022 where
40 percent of the Priority 1 posts on the Restrictive Housing Turnout Roster were
vacant and only 15 percent of the Priority 1 posts on the Building Turnout Roster were
vacant.
The separation of these rosters has created staffing silos that do not facilitate the
correct deployment of staff away from less critical posts (Building Turnout Roster) to
more critical posts (Restrictive Housing Turnout Roster).
In a follow-up interview with the Hughes Unit warden, he acknowledged issues with
this past practice and indicated he has recently personally begun moving staff between
rosters to allow for a better staffing balance.

PAGE 50
To address this concern, CGL recommends the elimination of multiple turnout rosters
at facilities in favor of a single combined roster.
18. Address Gaps in Annual In-Service Training. TDCJ acknowledges past gaps in annual
training due to the impact of the COVID-19 pandemic, and as staffing levels grow,
the agency should make every effort to address these gaps and ensure staff receive in-
service training as required. As part of annual training, the agency should elevate
those key security lapses identified during the Lopez escape review. These include
training regarding strip searches, application of restraints, managing inmates in
restrictive housing, and transportation supervision.
19. Institute Annual Refresher Training for Transportation Staff. New staff hired into the
Transportation Unit participate in the Offender Transportation Training Program, but
no annual transportation-specific retraining is required. TDCJ has recently
implemented a corrective action after the Lopez escape that included requiring
transportation supervisors regularly evaluate transportation officers while preparing
and conducting transports. We recommend this evaluation include some time
mentoring staff on transportation security requirements including searches, restraints,
and supervision.

PAGE 51

TDCJ Serious Incident Report and CGL Escaped Inmate Report

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Texas Department of Criminal Justice

EXECUTIVE SUMMARY ............................................................................. 1

Exhibit 1: Correctional Officer Vacancies/Vacancy Rate

8,000 7,598 7,613

TEXAS DEPARTMENT OF CRIMINAL JUSTICE

Exhibit 2: Hughes Unit Correctional Officer Vacancies/Vacancy Rate

TEXAS DEPARTMENT OF CRIMINAL JUSTICE

Exhibit 3: Hughes Unit Priority 1 Position Vacancies

TEXAS DEPARTMENT OF CRIMINAL JUSTICE

TDCJ Response to Incident. TDCJ implemented a multitude of corrective measures outlined in

CGL Recommendations. The following 19 recommendations address additional issues

TEXAS DEPARTMENT OF CRIMINAL JUSTICE

TEXAS DEPARTMENT OF CRIMINAL JUSTICE

Exhibit 4: TDCJ Transport Bus Configuration

TEXAS DEPARTMENT OF CRIMINAL JUSTICE

TEXAS DEPARTMENT OF CRIMINAL JUSTICE

TEXAS DEPARTMENT OF CRIMINAL JUSTICE

Chapter 2: Escapee Information

TEXAS DEPARTMENT OF CRIMINAL JUSTICE

Lopez’s medical history included and ( ) after

TEXAS DEPARTMENT OF CRIMINAL JUSTICE

Chapter 3: TDCJ Background

Exhibit 5: Historical TDCJ Inmate Population

120,873 119,498 118,081

TEXAS DEPARTMENT OF CRIMINAL JUSTICE

Exhibit 6: Total TDCJ Staff

40,000 35,717 36,257 35,066

TEXAS DEPARTMENT OF CRIMINAL JUSTICE

Exhibit 7: TDCJ Filled Correctional Officer Positions

Exhibit 8: Correctional Officer Vacancies/Vacancy Rate

8,000 7,598 7,613

TEXAS DEPARTMENT OF CRIMINAL JUSTICE

Exhibit 9: Hughes Unit Correctional Officer Vacancies/Vacancy Rate

TEXAS DEPARTMENT OF CRIMINAL JUSTICE

TEXAS DEPARTMENT OF CRIMINAL JUSTICE

Exhibit 10: Hughes Unit Restrictive Housing Rosters

Restrictive Housing Turnout Restrictive Housing Turnout

TEXAS DEPARTMENT OF CRIMINAL JUSTICE

Exhibit 11: Transportation Unit Filled Correctional Officer Positions

300 284 287 288 283

Exhibit 12: Transportation Unit Workload Metrics – FY17 to FY22

Total Inmates Total Miles

Decrease since FY 2017 -245,332.71 -521,804.31

TEXAS DEPARTMENT OF CRIMINAL JUSTICE

Exhibit 13: CRT CO Staffing – May 12, 2022

Allocated Positions 117

Staff on Leave/Inservice/Duties Outside CRT 17

TEXAS DEPARTMENT OF CRIMINAL JUSTICE

TEXAS DEPARTMENT OF CRIMINAL JUSTICE

Chapter 4: Escape Timeline/Description

Lopez then handed CO Smith a bag of

At 2:05 a.m. Sergeant Joshua Watson (Sgt.

At 9:34 a.m. Correctional Officers

TEXAS DEPARTMENT OF CRIMINAL JUSTICE

A short while later, video shows inmate

Lopez is then escorted to a small room

TEXAS DEPARTMENT OF CRIMINAL JUSTICE

At the completion of TCO Brinegar’s strip

TEXAS DEPARTMENT OF CRIMINAL JUSTICE

At 10:24 a.m. Lopez was

Exhibit 14: Transport Bus Configuration

3rd Officer Seat

Driver Seat Rear Compartment