It was 3:30 in the afternoon — count time on housing unit 5A at U.S. Penitentiary Atwater. Jose Rivera was a half-hour short of finishing his shift.
He had just announced the count, ordering the inmates under his charge — all 110 or so — to return to their cells. He began locking them down one by one, as he did every time he worked the eight-to-four.
It would be the last inmate count he'd conduct.
The two prisoners moved in, at least one of them clutching a sharp handmade shank. Rivera, a 22-year-old Navy veteran who'd started at USP Atwater less than 11 months earlier, hit the panic button on his radio.
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The other correctional officers were quick to respond. But the attack was quick, too. And brutal. By the time the officers got there, it was far too late.
Probably chosen by his attackers for no other reason than convenience, Rivera had been stabbed directly in the heart.
If the prisoners to blame were set on killing a correctional officer that Friday, then Rivera never really stood a chance, several of his former co-workers say.
He was by himself with more than 100 inmates. Backup was nowhere in sight. Strapped to his black duty belt were a radio, keys, a flashlight and a pair of handcuffs — no match for the well-armed population he oversaw. He was wearing slacks and a thin, white-collared shirt with no stab-resistant vest under or over it. The penitentiary didn't provide him one, and if he'd wanted to buy his own to wear, he wasn't allowed to.
Article continues below video
Editor’s note: This footage of a riot at US Penitentiary Atwater was shot in 2006 and uploaded to YouTube, according to correctional officers at the prison. The officers say the video shows how poorly equipped the prison is to respond to fights and attacks.
In the wake of Rivera's June 20 death, officials at USP Atwater and the U.S. Bureau of Prisons have declined to answer basic questions about what happened that day and about how Rivera was equipped: Where in the prison was he attacked? How many other officers were with him? How many were nearby? Was he carrying any weapons? Was he wearing a stab-resistant vest?
So the Sun-Star interviewed six current and former USP Atwater correctional officers. Two are still employed there. They asked for anonymity because the Bureau of Prisons has instructed them not to speak with reporters.
Four recently left the prison. Two allowed their names to be published. Two did not, one because he feared it could hurt his attempts to get a new job in law enforcement and the other because he still works for the Bureau of Prisons, the Washington, D.C.-based agency that oversees all federal correctional institutions.
Though they all said they were stunned by Rivera's death, none of them said it was surprising.
"It wasn't really a matter of if it was going to happen. It was more a matter of when — and to who," said James Spencer, a retired lieutenant who worked at the prison from its 2001 opening until last December. "I guess I'm surprised it didn't happen sooner, actually."
The current and former correctional officers, along with union officials, all said they think policies at USP Atwater are putting employees there at unnecessary risk — from inadequate staffing and a lack of protective equipment to too little control over the prison's 1,100 high-security inmates and too few consequences for the ones who act out violently.
They said their safety complaints and warnings to local, regional and national prison administrators have gone largely unanswered.
"It's getting worse and worse," said an officer who is planning to leave the penitentiary after about a year there because of his concerns over safety. "Sometimes there's attacks (on correctional officers) twice a week. Sometimes it's every three weeks or so. All I know is it's way more than it should be … and not enough is being done to try to protect us."
No officials from USP Atwater or the Bureau of Prisons would answer questions for this story.
Just not enough staff
All the current and former correctional officers interviewed said inadequate staffing at the prison has made it unsafe there for both employees and inmates.
"There just aren't enough staff to do things the right way," said Ryan Silva, who left USP Atwater last month after working 12 years for the Bureau of Prisons, the last seven of them in Atwater. "It's dangerous. We've been saying that for a while."
Officials with the Bureau of Prisons have said USP Atwater actually has a better staff-to-inmate ratio than most comparable federal facilities: The systemwide average for similar federal prisons is about one staff person for every five prisoners, compared to a 1-to-4 ratio at the Atwater facility.
Union officials argue that staffing across the federal prison system is drastically inadequate, and correctional officers at USP Atwater said the 1-to-4 figure is misleading.
"If you divide the total number of people who work there by the total number of inmates, it probably comes out to 1-to-4, and that doesn't sound too bad," the officer who started about a year ago said. "But that includes every employee — from the secretaries to the dental technicians. And not all the staff are there for every shift, obviously. The inmates are. ... After 4 p.m., it's a skeleton crew."
Inside each of USP Atwater's 12 housing units, one correctional officer is typically alone with at least 100 inmates, the officers interviewed said. The housing units are separated and configured in such a way that officers in nearby units can't easily see inside or quickly access other units.
"That means you're pretty much on your own in there," said the officer who recently left the Bureau of Prisons after several years at USP Atwater.
Between 4 p.m. and 8 a.m., the officers interviewed said, about 25 employees are left oversee the prison's entire 1,100-inmate population.
Union officials have been calling for more staff across the federal system for years — and they are renewing those calls in light of Rivera's death.
"Our officers are in grave danger. It's that simple, and we've been shouting it for quite some time," said Bryan Lowry, president of the Council of Prison Locals of the American Federation of Government Employees. "Staffing is decreasing while inmate populations are increasing. We're also dealing with a far more aggressive population than we were five years ago."
No one from the Bureau of Prisons would provide information on how staffing levels have changed at USP Atwater over the years. Lowry said that systemwide the bureau would have to hire about 9,000 people to reach the same staff-to-inmate ratios it maintained 20 years ago.
Though some of the officers interviewed said USP Atwater has always been understaffed, most said it was manageable before 2005.
After Congress reduced funding for federal prisons that year, the director of the Bureau of Prisons, Harley Lappin, ordered staffing cuts across the system — reducing correctional employee rosters to what were termed "mission-critical posts."
Lowry estimated 2,300 positions were cut inside federal prisons across the country as a result. Atwater gave up dozens of posts, the officers interviewed said.
"It was at least a handful of people on each shift," Silva said. "We definitely felt the difference."
Among the corrections positions eliminated were several "observation" posts.
Before the cuts, one observation officer was typically assigned to every two housing units. In effect, the observation officers meant that every two housing units had three officers. Now each unit has just one.
"It was basically a backup who floated between two units," the officer who recently left the Bureau of Prisons said. "If he wasn't on your unit with you, he was always right there."
Spencer, the lieutenant who left USP Atwater last year, said: "I think Jose Rivera would still be alive today if it wasn't for that position being taken away."
Overtime used daily
Since its opening USP Atwater hasn't filled all the correctional officer positions it is allotted. It's now one of four federal prisons in California offering signing bonuses to fill an "urgent need of correctional officers," according to the Bureau of Prisons' Web site.
Lowry said about 15 percent of positions at USP Atwater are vacant, though he disputed claims that the jobs are open because the prison can't find qualified people to fill them. Instead, he said he believes the prison holds positions open to save money on salary and benefits costs.
"It's a cost-savings measure," Lowry said. "They could fill more of those jobs if they wanted to."
Some officials have argued the shortage hasn't added to safety problems because all the prison's shifts are filled with employees working overtime.
The officers interviewed disagreed. "If you're working 16-hour shifts, you're fatigued," the officer who started about a year ago said. "You're less aware of your surroundings and sometimes that awareness is all you have to protect you."
Mandatory overtime is used daily to fill shifts, the officers said.
They said a change in USP Atwater's operating procedure in 2006 worsened staffing issues.
For its first five years, the penitentiary was divided into east and west sides, and procedure said that only half the population — or one side of the prison — was allowed outside its housing units at a time.
In 2006, a mandate from the Bureau of Prisons opened Atwater's divided compound, allowing all its inmates to be outside their housing units — at meals, on the yard, at church or in classes — at once.
"It basically cut our force in half," said a correctional officer who has worked at USP Atwater since 2003. "Before, we never had more than 600 or 700 inmates moving at a time. After that, we were dealing with all 1,200 or 1,400 at the same time, but with the same number of staff out on the compound."
Local union officials tried to block the change. They wrote letters to Congress and circulated a petition against it. "We fought it tooth-and-nail," said the officer who recently left USP Atwater to work at another federal prison.
In a letter to Rep. Dennis Cardoza, Phillip Rodriguez, then-president of the local union, wrote: "The system at Atwater is not broken, yet if this change is implemented then it will break. ... I was at the Federal Penitentiary in Lompoc when (correctional officer) Scott Williams was murdered by an inmate in 1997. I wish never to go through that again. … Why would a decision be made to increase that likelihood?"
Those concerns proved valid, Spencer said. "Before 2005, we had a safe facility. After that it just wasn't manageable. … There were more fights, more attacks and more contraband being passed between inmates," including weapons.
A spokesman for the Bureau of Prisons said he couldn't provide information on the number of assaults and fights reported at USP Atwater in recent years, but the officers interviewed said they've increased dramatically.
Atwater led the federal prison system in armed assaults by inmates on staff in 2006, with 10 such attacks, according to union officials. "We went from being the safest facility in the bureau to one of the most dangerous," Spencer said.
As attacks on employees have increased, news of them rarely makes it outside the prison's walls, the officers interviewed said. Less serious assaults — inmates spitting at officers or intentionally bumping into them — happen daily, the officers said. Serious attacks that require medical treatment are becoming almost monthly occurrences, some said.
All of the officers described USP Atwater's inmates as a well-armed population.
"I would say that almost every guy in there probably has some kind of sharp weapon on him," the officer who started about a year ago said. "If not, he's got one stashed somewhere real close."
Atwater's correctional officers carry no weapons, the officers said. They don't wear stab-resistant vests or any other protective gear. "We have keys, cuffs and a radio — and that's it," the same officer said. "It's like bringing a knife to a gun fight — or like bringing nothing, really."
He added, "With the vests, it's not just a money thing. They're really expensive, but even if you wanted to get your own, you wouldn't be allowed to wear it because it's not part of the approved uniform. Because they don't want you to look too authoritative."
The Bureau of Prisons has a number of policies aimed at making staff inside federal prisons seem less authoritative, the officers interviewed said.
"That's the reason that's given for why we can't carry (nonlethal) weapons, why we wear the uniforms we wear and why we can't have the stab vests," Silva said. "(Administration) says it would send the wrong message if we looked too much like police or the military. ... I don't really understand it."
Union officials said the same thing. "We've been calling for stab-resistant vests for two years," Lowry said. "Basically, (administration) says they don't want to send alarming signals to the public by admitting vests are necessary — or they don't want to send mixed messages to inmates. … When an officer's been murdered, it's time to get past all that."
The officers interviewed said they agreed with many bureau policies geared toward a less authoritative approach. "I think it's a good concept," Spencer said. "I agreed with the uniforms and I agree that we should be relying on open communication with inmates as much as possible. Showing them respect is important."
He added: "But we should have had vests from day one. There's no excuse for that."
It's routine that prison guards don't carry guns. But many outside the federal system carry nonlethal weapons.
All California state correctional officers wear stab-resistant vests and carry expandable batons and pepper spray, said Terry Thornton, a spokeswoman for the California Department of Corrections and Rehabilitation.
Correctional officers inside Merced County's jails carry Tasers. They began wearing stab-resistant vests last year.
"When you know the inmates have weapons, it just make sense," Silva said.
He and other officers interviewed said the prison doesn't adequately search for and confiscate weapons, mostly because it doesn't have enough staff. "If they paid for a shakedown crew, it would help a lot," Silva said. "But they don't."
Correctional officers posted to USP Atwater's housing units are supposed to randomly search inmates and cells every shift they work, but searches of all inmates and all the areas they could stash weapons are rare, the officers said.
"If we do a full shakedown — and they're not very thorough shakedowns — we'll usually recover at least 100 weapons," the officer who started in 2003 said. "Inmates can make weapons out of almost anything."
The only lethal weapons kept by USP Atwater stay in the prison's tower, the officers said. The only nonlethal weapons kept by the prison are stored in a control center about a quarter-mile away from some housing units.
The officers interviewed said consequences levied after prisoners are caught carrying weapons or acting violently aren't harsh enough, adding to safety problems.
Specifically, they said inmates who act out should be placed in the prison's lockdown unit more often and for longer periods of time. Inmates frequently avoid such punishment because Atwater's lockdown unit is overcrowded, they said.
Prison-wide lockdowns often aren't put into effect after inmate fights and attacks, and when they are, they're too short, the officers said.
During lockdowns inmates aren't allowed to see visitors, make phone calls or leave their cells except to shower, so the lockdowns serve both as security measures and as punishment.
A Bureau of Prisons spokesman said he couldn't answer questions about the bureau's lockdown policies, but the officers interviewed said most lockdowns at USP Atwater last two days or less, even after serious attacks on staff.
"For anything longer than that you need approval from the bureau," Spencer said. "Almost always, the lockdowns aren't long enough to really be effective. The institution should be kept on lockdown until a majority of the staff feels safe, but that's not usually what happens."
In October, local union officials filed a grievance with the director of the the Bureau of Prisons' western region, Robert McFadden, stating that short and inconsistent lockdowns are putting staff and inmates at USP Atwater at risk.
"(It's) resulting in a more aggressive inmate population," the grievance stated. "The agency's inaction has resulted in an increase in assaults on inmates and staff in recent months."
Two months later, McFadden responded that the grievance wasn't specific enough. "I trust this addresses your concerns," he wrote.
After an inmate punched a correctional officer in the face late last year, breaking his jaw in several places, USP Atwater was placed on lockdown for about a day, several officers said.
They said systemwide lockdowns are very rare. One officer said the last he could remember was over a decade ago. California state prisons use systemwide lockdowns far more often.
"When there's no serious consequences, there's no accountability," the officer who started at USP Atwater about a year ago said. " It sort of becomes an institution run by the inmates."
Silva said he thinks the problem extends across the federal prison system. "There's a core value that comes down from the bureau that we should try not to agitate the inmates, so they frown on long lockdowns," he said. "That seems really reckless to me because (inmates) learn really quick that there's no point in behaving."
Still no comment
USP Atwater's spokesman, Jesse Gonzalez, declined to answer any questions about the prison this week. Dennis Smith, the third warden to oversee USP Atwater since its opening, didn't return phone calls.
Lappin, the director of the Bureau of Prisons, couldn't be reached. Calls to his office were directed to the bureau's spokesman, as were calls to McFadden, the regional director who oversees USP Atwater.
The bureau's spokesman, Mike Truman, said he could only answer questions submitted to him in writing. The Sun-Star e-mailed him a list of questions Tuesday morning. On Wednesday afternoon he said he couldn't answer any of them because he needed more time to prepare answers.
Rivera, who lived in Chowchilla, was buried last week. He had worked at USP Atwater about 10 months.
The third of five children, he graduated from Le Grand High School in 2003 and enlisted in the U.S. Navy shortly after. He served four years in the military, including two tours in Iraq.
The FBI's Fresno office is investigating his death. The Bureau of Prisons has declined to turn over to union officials video surveillance footage of his stabbing, Lowry said.
The two inmates suspected of killing Rivera, James Leon Guerrero and Joseph Cabrera Sablan, haven't been charged.
Both of them come from Guam, a U.S. territory, and both were transferred off the island because of their violent behavior inside a prison there. One has been accused of killing a correctional officer before, though he wasn't convicted. They are longtime friends, according to corrections officials in Guam. One of them arrived at USP Atwater the day before Rivera's death.
Most of the correctional officers interviewed said they don't think the Bureau of Prisons or USP Atwater will change any safety-related policies as a result of Rivera's death.
Lowry said union officials are renewing their calls for adequate staffing, stab-resistant vests and non-lethal weapons. "I think there will be some changes, but I think it will be very slow," he said. "We're talking about changing the culture — the attitude — of an entire agency, really."
Congressman Cardoza said Wednesday that he also is asking for stab-resistant vests and more funding to fully staff federal prisons. If the Bureau of Prisons doesn't comply, Cardoza said he plans to introduce legislation that would require vests for all federal correctional officers.