After two inmates escaped, allegedly killing two correctional officers early one June morning, the state Department of Corrections vowed to make changes to address security lapses that led to the tragedy.

A month after funerals were held for the two slain correctional guards, Corrections Commissioner Greg Dozier released a 53-page internal report promising changes would be made to prevent “an event like this” from ever happening again.

Some of the proposed changes were simple, requiring adjustments in policies and practices, while others involving buying additional security equipment.

Six months later, the Department of Corrections is still working on making changes.

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When asked by The Atlanta Journal-Constitution to provide records of the progress made toward preventing another deadly escape, the state Department of Corrections said it would not release documents detailing the specifics of that work now, because they are still “vetting” the information.

“We have been, and continue to work on implementing and/or reviewing each and every recommendation listed in the external report,” Department of Corrections spokeswoman Joan Heath said in an email.

Eatonton, GA - Ricky Dubose (front) and Donnie Russsell Rowe enter the Putnam County courthouse last June for their first court apperance after they were re-captured. BOB ANDRES /BANDRES@AJC.COM

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“The fact that not all recommendations are fully implemented (all are in some percentage of completion) as of today does not mean we are not working to do so, it simply means we are ensuring this process is completed thoroughly,” Heath said. “We are looking forward to being able to release the fully vetted, thoroughly completed documents outlining all of the changes just as soon as possible.

Among changes she listed that have already begun were refresher training for prisoner transport officers and installation of cameras and upgraded locks for transport buses.

Prison operations expert Steve Martin said bureaucracy may be one reason many improvements have not been made.

“That type of thing, bureaucratic systems, can take a long time — purchasing (items), getting them in,” Martin said.

The danger of routine

It was before daybreak on Tuesday, June 13, when convicted armed robbers Donnie Russell Rowe and Ricky Dubose freed themselves from their handcuffs onboard a prison bus. They allegedly used a smuggled toothbrush to pry off an open padlock on a gate separating the inmates from the guards driving the bus. Once the inmates reached the guards, they took their guns and shot Sgts. Curtis Billue and Christopher Monica, leaving their bodies on the front seats.

Within moments, the two convicts reportedly carjacked a Honda that had stopped behind the prison bus on Ga. 16 in Putnam County. Local, state and federal law enforcement chased the fugitives for three days. They caught up with them in another car stolen from a couple they had allegedly held hostage for several hours. The manhunt ended with a crash near Murfreesboro, Tenn.

The prosecutor in the eight-county Ocmulgee Judicial Circuit announced almost immediately that he would seek the death penalty if Rowe and Dubose are convicted of murder.

Curtis Billue, 58 was one of two Georgia correctional officers shot and killed by prison inmates they were transporting. Billue worked in the Department of Corrections for a decade.

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"This is very clearly a death penalty case," Ocmulgee Judicial Circuit District Attorney Stephen Bradley said when the two accused murderers first appeared in court to formally hear the charges against them.

When Dozier, the corrections commissioner, made public a report on the escape, it pointed to staffing issues and the danger of being lulled into a routine when moving prisoners by bus.

Prison operations expert Martin confirmed that out of habit, officers can sometimes go through the motions without much effort or thought, and “inmates, all they have to do is sit around and observe and watch and they pick up on the habits of officers.”

Georgia Department of Corrections Commissioner, Gregory C. Dozier, presents the results of an investigation into how two inmates were able to escape custody and kill two correctional officers on June 13, 2017. Chad Rhym/ Chad.Rhym@ajc.com

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Around the state on any given Tuesday or Thursday, the regular days for moving inmates, there are 15 buses carrying about 800 inmates to court appearances or educational programs or to prisons with higher or lower security or to get them away from certain inmates. Mondays and Wednesdays are set aside to move inmates in need of medical care; 60 to 65 vans carry an average of 85 inmates on each of those days.

Dozier noted unconfirmed reports that Sgt. Monica, who was in the passenger seat of the prisoner’s transport bus the day of the escape, dozed off and on during the ride, which began at 3:30 a.m. when inmates at Baldwin State Prison in Hardwick were loaded onto the bus.

Records later obtained by the AJC showed Monica worked extra days almost every week for at least three months before he was killed. Monica’s regular schedule allowed for a four-day work week — Monday through Thursday — but he also regularly worked 13- and 14-hour shifts. He also worked on his days off, sometimes for two or three weeks without a break.

His work schedule was exhausting. Friends and family said he put in the overtime so he could support his medically-disabled his wife and their children.

The Department of Corrections did not respond to several requests about systems the agency has in place to ensure officers are not working so much that their alertness could be diminished.

Overtime is almost always available for anyone who wants it, because the entire state prison system is short of correctional officers.

“If a system has a persistent staff deficiency, part of the management of that deficiency is setting limits on overtime,” said Martin, a consultant who has worked in state and federal prisons and has served as a court-appointed monitor. “When staff has worked so many hours, you have compromised that position. You cannot expect a staff to work 16-plus hours five days a week. Systems that allow their officer to work these extraordinary hours because they want them, that’s going to lead you down the path to perdition.”

More changes needed

The internal report noted there were stretches of time that Billue and Monica left inmates on the bus unsupervised while they went inside Baldwin State Prison and then Hancock State Prison to get other convicts. It is not known if DOC has made changes that would ensure there are enough guards to bring inmates out so transport officers can stay with the bus or van.

Another finding in the report was that a video camera trained on the inmates recorded images of the prisoners getting out of their cuffs. But apparently neither officer noticed that inmates — not just Dubose and Lowe — were moving around in the back of the van.

One change to prisoner transport procedures has been put in place almost immediately. A "trailing vehicle" now follows every van and bus moving inmates. When Lowe and Dubose escaped, there was no backup following the bus carrying 33 inmates. Billeu, 58, and Monica, 42, got away in a Honda that pulled up behind the bus.

While the internal report from last summer said “the officers’ failure to secure the gate was the single greatest point of failure,” the agency has not yet installed better locks for the gates that separate inmates on transport buses, nor has it acquired handcuffs and leg irons that double lock.

“The locking mechanisms are in progress, as we continue to review best options,” Heath said. “We have been working on installation of new cameras, have continued the new transport training, implemented the trail vehicles, reviewed and begun to install locking mechanisms, among others.”

Heath said more changes to prison transport security will be made and that information on the upgrades will be shared with the public.

“The fact that not all recommendations are fully implemented (all are in some percentage of completion) as of today does not mean we are not working to do so, it simply means we are ensuring this process is completed thoroughly. We are looking forward to being able to release the fully vetted, thoroughly completed documents outlining all of the changes just as soon as possible.”