Office of the Inspector General

Office of the Inspector General U.S. Department of Justice OVERSIGHT * INTEGRITY * GUIDANCE Review and Inspection of Metropolitan Detention Center Brooklyn Facilities Issues and Related Impacts on Inmates Evaluation and Inspections Division 19-04 September 2019 EFTA00127743 Executive Summary Review arid Inspection of Metropolitan Detention Center Brooklyn Facilities Issues and Related Impacts on Inmates Introduction According to the Federal Bureau of Prisons (BOP), Metropolitan Detention Center (MDC) Brooklyn is an administrative security Metropolitan Detention Center that houses approximately 1,700 federal pretrial inmates and federal inmates serving sentences (herein collectively referred to as inmates). On Sunday, January 27, 2019, MDC Brooklyn experienced an electrical fire that caused a partial power outage in its West Building. Although the fire was contained soon after it began, the partial power outage lasted a full week—until Sunday, February 3. The outage affected lighting in housing areas, computers, phones, and other institution systems and equipment. As a result, MDC Brooklyn canceled legal and social visiting that week. Throughout the 7-day power outage, inmates, their attorneys and families, the public, and members of Congress (all of whom we refer to as stakeholders) expressed concerns that inmates were not receiving food and appropriate medical attention and that the facility was without heat. The power outage coincided with a 6-day period of extremely cold temperatures in New York City. with a low temperature of 2 degrees Fahrenheit on January 31. Given the significance of these issues and concerns, on February 7, 2019, the Office of the Inspector General (OIG) initiated a review and inspection of MDC Brooklyn to determine whether the BOP took appropriate steps to address issues caused by the fire and power outage, how those issues affected the conditions of confinement. and whether the BOP had in place adequate contingency plans to respond to such an incident. Results in Brief We found that during the power outage there were significant heating issues at MDC Brooklyn. These heating issues were unrelated to the fire and subsequent power outage. which did not affect MDC Brooklyn's heating systems. Instead, long-standing temperature regulation issues caused temperatures in certain housing units in MDC Brooklyn's West Building to drop below the BOP target of 68 degrees before, during, and after the power outage. We found that MDC Brooklyn and BOP management took steps to ensure the safety and security of the facility during the power outage but failed to effectively manage other critical aspects of the situation. Specifically, MDC Brooklyn and the BOP did not effectively address two medical issues and did not effectively communicate with stakeholders MDC Brooklyn's decision to suspend legal and social visiting I during the power outage. This was particularly problematic in view of MDC Brooklyn's population of pretrial inmates. Moreover, MDC Brooklyn and BOP management did not provide sufficient notice or information to the public about the fire and the effect of the power outage on conditions of confinement, including that the power outage did not affect heating in the facility. As a result, within days of the fire, there was extensive media reporting about conditions at MDC Brooklyn with a lack of definitive information from the BOP; multiple legal actions were filed against the BOP; numerous members of Congress expressed concerns about facility conditions and sought to visit MDC Brooklyn; and inmates became disruptive following protests outside the facility. Accordingly, we found that existing MDC Brooklyn contingency plans do not address how and when staff should alert and update external stakeholders about significant disruptions at the facility that affect legal and social visits and conditions of confinement. Updates to contingency plans and policies, which consider the information needs of stakeholders as well as their roles in the criminal justice system, would assist the BOP in more effectively managing crisis situations. The BOP Failed to Adequately Address Preexisting Heating and Cooling Issues at MDC Brooklyn, Resulting in Certain Inmate Housing Areas Being Below the BOP Target Temperature in January and February 2019 We found that before, during, and after the January power outage, temperatures in MDC Brooklyn's West Building occasionally fell below the BOP's winter target of 68 degrees for periods of time, with the coldest recorded temperature at 59 degrees 1 week before the fire. We also found that temperature regulation issues at the facility resulted in winter temperatures in certain parts of the West Building far exceeding 68 degrees, including temperatures in excess of 80 degrees. MDC Brooklyn staff have long struggled to regulate temperatures in the West Building. According to facilities staff, a significant reason for this is that MDC Brooklyn has not installed a Building Management System (BMS), which would continuously monitor building temperatures and heating and cooling equipment functionality. Additionally, a BMS would allow facilities staff to make corrective adjustments more quickly. Absent a BMS, we found that facilities staff used an unreliable method to measure West Building temperatures before and during the power outage. As a result, we cannot state with reasonable assurance how many inmate housing areas experienced temperatures at or below the BOP target of 68 degrees or for how long localized temperatures remained below EFTA00127744 • I ......... tt ti 1/ it iiibiiii• IOW C i 11k Executive Summary Review and Inspection of Metropolitan Detention Center Brooklyn Facilities Issues and Related Impacts on Inmates the target. Though inmates' temperature sensitivities may vary, multiple inmates housed in units experiencing temperatures below 68 told us that they were "freezing" or very cold during the power outage. We also found that environmental factors other than ambient air temperature could have made inmates feel colder. First, exterior cell walls, which abut inmate beds, can have surface temperatures well below the ambient air temperature. Second, airflows out of cell heating and cooling vents were at high speeds, making it difficult for inmates to avoid exposure to fast moving air. Third, cold-weather clothing such as thermal underwear and sweat suits are not standard issue at MDC Brooklyn. Although available ambient air temperature readings did not indicate actual freezing temperatures (i.e., below 32 degrees), these factors likely contributed to the conditions that some inmates described as very cold or freezing. MDC Brooklyn Management Took Steps to Ensure the Safety and Security of the Facility During the Power Outage but Did Not Effectively Address Heating and Two Medical Issues We found that MDC Brooklyn and BOP management took several steps to ensure the safety and security of the institution. For example, the Warden followed the institution's fire contingency plan, which included notifying regional BOP management and the BOP's Central Office of the situation. MDC Brooklyn management also decided to keep inmates secured in their cells for certain periods to maintain safety. The Warden also made the judgment, which was supported by the acting BOP Director, not to evacuate the jail because doing so would have presented a greater security risk than keeping the inmates at MDC Brooklyn. While these judgments were not unreasonable, we found certain significant flaws in the facility's management during the week of the power outage. First, as described above, the MDC Brooklyn management did not effectively handle preexisting temperature regulation problems at the facility, which became an issue once again during the power outage because of the extremely cold temperatures outside. Second, although the decision to cancel in-person legal and social visiting during the power outage due to existing security concerns was not unreasonable under the circumstances, we believe that MDC Brooklyn management could have better prepared for this contingency by having an alternative visitation plan available to use once it became clear that the power outage would not be resolved promptly. Third, we found that, while medical rounds continued during the week of the power outage, preparations were not made to handle inmates who used continuous positive airway pressure machines. Further, although MDC Brooklyn management told us inmates could have submitted paper requests for refills of certain medications, we found that the standard electronic request method was unavailable during the power outage. Fourth, we found that MDC Brooklyn management could have done more to communicate to inmates and staff the circumstances surrounding the power outage and alternative methods for accessing vital services, such as communicating with counsel and requesting prescription refills, when telephones and inmate computer systems were unavailable. The BOP Did Not Communicate the Status of Conditions at the Facility During the Power Outage or the Reason for Canceling Legal and Social Visits in a Sufficient or Timely Manner MDC Brooklyn and the BOP did not take sufficient proactive steps to inform defense counsel, the courts, inmates' family members, the public, and members of Congress about the effect of the power outage on legal and social visiting and the conditions of confinement at MDC Brooklyn in the aftermath of the fire. In fact, the BOP did not issue a press release until 6 days after the fire, and then only in response to media reporting that highlighted criticisms of MDC Brooklyn's management of the situation. This lack of information contributed to confusion about the nature of the situation at the facility, which in turn contributed to disruptions by inmates inside the jail, protests outside the jail, multiple judicial actions, congressional scrutiny, and rumors and speculation about the seriousness of conditions at the facility. We believe that these problems were due, in part, to the fact that the BOP underestimated the degree of public interest in the effect of the fire and power outage on conditions at MDC Brooklyn and because MDC Brooklyn contingency plans did not provide sufficient guidance to staff about alerting and updating extemal stakeholders about significant events that disrupt visiting and significantly affect conditions of confinement. Recommendations We make nine recommendations to ensure that the BOP is better able to minimize the effect that future facilities issues and disruptive events have on inmates at MDC Brooklyn and other BOP institutions. EFTA00127745 TABLE OF CONTENTS INTRODUCTION 1 Background 1 MDC Brooklyn 2 Male Inmate Management 2 Legal and Social Visiting for Male Inmates 4 West Building Electrical System 4 The January 27 Fire, 7-day Power Outage, and Electrical Repair 5 Prior OIG Work Related to MDC Brooklyn 8 Scope and Methodology of the OIG Review and Inspection 9 TIMELINE OF MAJOR EVENTS AT MDC BROOKLYN, JANUARY 27- FEBRUARY 3, 2019 10 RESULTS OF THE REVEW 11 The BOP Failed to Adequately Address Preexisting Heating and Cooling Issues at MDC Brooklyn, Resulting in Certain Inmate Housing Areas Being Below the BOP Target Temperature in January and February 2019 11 MDC Brooklyn Management Took Steps to Ensure the Safety and Security of the Facility During the Power Outage but Did Not Effectively Address Heating and Two Medical Issues 22 The BOP Did Not Communicate the Status of Conditions at the Facility During the Power Outage or the Reason for Canceling Legal and Social Visits in a Sufficient or Timely Manner 31 CONCLUSION AND RECOMMENDATIONS 41 Conclusion 41 Recommendations 42 APPENDIX 1: PURPOSE, SCOPE, AND, METHODOLOGY 44 Standards 44 Site Visits 44 Interviews 44 Data Analysis 45 iii EFTA00127746 Document and Policy Review 46 APPENDIX 2: OTHER MDC BROOKLYN HVAC ISSUES 47 APPENDIX 3: JUDICIAL ACTIONS RELEVANT TO THE MDC BROOKLYN FIRE AND POWER OUTAGE 48 APPENDIX 4: FIRST BOP PRESS RELEASE ADDRESSING THE MDC BROOKLYN POWER OUTAGE 49 APPENDIX 5: SECOND BOP PRESS RELEASE ADDRESSING THE MDC BROOKLYN POWER OUTAGE 50 APPENDIX 6: DOJ PRESS RELEASE ADDRESSING THE MDC BROOKLYN POWER OUTAGE 51 APPENDIX 7: THE BOP'S RESPONSE TO THE DRAFT REPORT 52 APPENDIX 8: OIG ANALYSIS OF THE BOP'S RESPONSE 56 iv EFTA00127747 INTRODUCTION Background On Sunday, January 27, 2019, an electrical fire at the Federal Bureau of Prisons' (BOP) Metropolitan Detention Center (MDC) Brooklyn caused a partial power outage in its West Building, which houses male federal pretrial inmates and federal inmates serving sentences) Although the fire was contained soon after it began, the partial power outage lasted a full week—until Sunday, February 3 (see the Timeline of Major Events at MDC Brooklyn). The outage affected the West Building's lighting and electrical outlets in inmate cells and common areas, inmate and staff computer systems, inmate phones, and other systems and equipment. 2 Due to the outage, MDC Brooklyn canceled legal and social visiting for the entire MDC facility, limiting inmates' access to legal counsel during the week.3 Concerns were also raised that parts of MDC Brooklyn were without heat and inmates were not receiving food and appropriate medical attention during the outage.° Given the significance of these issues, and in response to both congressional and U.S. Department of Justice (Department, DOJ) requests, on February 7, 2019, the DOJ Office of the Inspector General (OIG) initiated a review and inspection of MDC Brooklyn to determine whether the BOP took appropriate steps to address issues caused by the fire and power outage, how those issues affected the conditions of confinement for inmates, and whether the BOP had in place adequate contingency plans for such an incident.5 According to 28 C.F.R. § 551.101, the term "pretrial inmate" describes "a person who is legally detained but for whom the Bureau of Prisons has not received notification of conviction. Thus, a 'pretrial inmate' ordinarily includes a person awaiting trial, being tried, or waiting a verdict." MDC Brooklyn houses approximately 1,700 federal pretrial inmates and federal inmates serving sentences (herein collectively referred to as inmates). 2 The fire did not affect the power supply to MDC Brooklyn's East Building, which houses female inmates. 3 Inmate housing unit telephones that connect directly to the Federal Defenders of New York were operational during the power outage. Therefore, inmates represented by the Federal Defenders of New York could speak with counsel by telephone. 4 For example, public defenders, Federal Defenders of New York, Inc. v. Federal Bureau of Prisons and Warden Herman Quay (E.D.N.Y., filed Feb. 4, 2019); media reporting, "No Heat for Days at a Jail in Brooklyn Where Hundreds of Inmates Are Sick and 'Frantic,' " The New York Times, February 1, 2019, and "Power Restored to Brooklyn Jail Where Inmates Went a Week Without Heat," NPR, February 4, 2019. See also Jerry Nadler, Press Release, "Lawmakers Press for Answers. Following MDC BK Heat. Power Outage " February 6, 2019, www.nadler.house.govinews/documentsingle.aspx?DocumentID=392787 (accessed September 17, 2019). 5 U.S. Congress, letter to Michael E. Horowitz, Inspector General, U.S. Department of Justice, February 6, 2019, www.velazquez.house.gov/sitesivelazquez.house.gov/files/02-06- 19%20D000200IG'/020letter%2Ore%20MDCY020Brooklyn.pdf, and BOP, Press Release 'Statement on MDC Brooklyn ssues," February 6, 2019, wvwv.int.nyt.com/data/documenthelper/600-the-department-of- justice-stat/651039689cdea2771cc6/optimized/full.pdf (both accessed September 17, 2019). 1 EFTA00127748 MDC Brooklyn MDC Brooklyn is the largest federal Metropolitan Detention Center in the country and houses approximately 1,700 male inmates in its West Building and approximately 40 female inmates in its East Building. When the Special Housing Unit (SHU) in the West Building is at capacity, MDC will house additional male SHU inmates in the East Building.' The institution's mission is to house federal inmates from the New York City metropolitan area who are processing through the federal judicial system. As an administrative security facility, MDC Brooklyn houses inmates at all security levels, sometimes including high-profile inmates with a variety of criminal histories, including terrorism, organized crime, and drug smuggling.' Generally, MDC Brooklyn houses inmates on a short-term basis, averaging 120 to 180 days. After inmates are convicted and sentenced, the BOP assigns them to one of its long-term correctional facilities. MDC Brooklyn's West Building houses male inmates in 18 housing units on 6 floors. The two units on the top floor are SHUs, which house inmates who are either on administrative detention or in disciplinary segregation.' The East Building houses female inmates in one housing unit on one floor, and, as stated above, also houses male inmates in one additional SHU on another floor. The two buildings are connected by an underground tunnel, which MDC Brooklyn staff call "the link." Male Inmate Management On a typical day, MDC Brooklyn Correctional Officers release non-SHU inmates from their cells at 6 a.m. and inmates can occupy the housing unit common area until they are secured for the evening following a 9:30 p.m. inmate accountability check. Each unit, which can house more than 100 inmates, is supervised by 1 Correctional Officer. Throughout the day, inmates can eat and socialize in the common area; attend Education, Religious, or Psychology Department programming; and utilize unit recreation facilities, such as a caged recreation deck with outdoor exposure. During the normal course of operations, inmates can also use: • private showers located in the common area; • The West Building opened in November 1999. The West Building has a rated capacity of 1,753 male inmates. The East Building opened in January 1994. The rated capacity of the East Building, as currently configured, is 125 female inmates. 7 Administrative facilities are institutions with special missions, and inmates are assigned to them based on factors other than security and/or staff supervision (for example, medicaVmental health issues or pretrial or holdover status). See BOP Program Statement 5100.08, Inmate Security Designation and Custody Classification, September 12, 2006. • Administrative detention status removes the inmate from the general population when necessary to ensure the safety, security, and orderly operation of correctional facilities or to protect the public. Administrative detention status applies only to SHU inmates, is non-punitive, and can occur for a variety of reasons, according to the BOP. Disciplinary segregation status is a punitive status imposed only by a Discipline Hearing Officer as a sanction for committing prohibited acts. See BOP Program Statement 5270.11, Special Housing Units, November 11, 2016. 2 EFTA00127749 • laundry machines to wash personal clothing; • phones to speak with family, friends, and legal counsel ;9 • unmonitored phones that connect to the Federal Defenders of New York;10 and • monitored computers to perform legal research, request nonemergency medical attention, refill prescriptions, and communicate with friends and family." Inmates who work in Food Services prepare meals in a central kitchen inside the West Building, and Correctional Officers then deliver large meal carts to each unit.12 Breakfast is usually a cold meal, whereas lunch and dinner are hot meals. During typical weekday operations, Correctional Officers deliver breakfast to the housing units around 7 a.m., lunch around 11 a.m., and dinner around 5 p.m. Before dinner, from 4 to 4:30 p.m., Correctional Officers perform a census count, during which all inmates are confined to their cells. MDC Brooklyn's Health Services staff deliver required medication or insulin to inmates every morning and evening. Inmates line up in their housing unit common area, and a staff member administers the prescribed dosages. If inmates are confined to their cells, Health Services staff administer prescribed dosages to inmates at their cells. Staff and inmates refer to these deliveries as "pill line" and "insulin line." Pill line and insulin line may occur simultaneously or at different times, meaning that Health Services staff make two to four visits to each housing unit every day. Health Services staff provide inmates with multiday supplies of certain drugs that have a low risk of abuse, and inmates are encouraged to request a refill through the inmate computer system within 5 days of exhausting their supply. If inmates cannot make a timely electronic request, they can make a written request or ask Health Services staff for a refill during pill or insulin line. Inmates in the SHU are confined to their cells for 23 hours per day and are allowed 1 hour of outdoor recreation time. Like inmates in regular housing units, SHU inmates receive three meals a day and, if necessary, medication or insulin twice a day. Unlike cells in regular housing units, SHU cells have a shower. SHU 9 The BOP monitors all calls made on inmate phones. If inmates need to make an unmonitored legal call to a private attorney, they can use staff phones. I° The Federal Defenders of New York represents clients in the Eastern and Southern Districts of New York who have been charged with federal crimes and cannot afford to hire an attorney. See Federal Defenders of New York, "About www.federaldefendersny.org/about-us (accessed September 17, 2019). Only inmates represented by the Federal Defenders of New York are allowed to use these unmonitored phones. 11 BOP inmate computer systems allow inmates to perform legal research, request nonemergency medical attention, refill prescriptions, communicate with friends and family, and file Prison Rape Elimination Act of 2003 complaints. 12 Though the BOP generally requires sentenced inmates to work, pretrial inmates are not required to do so. However, some pretrial inmates choose to perform paid work in a number of capacities at MDC Brooklyn. 3 EFTA00127750 inmates may have unlimited contact with legal counsel, but they can make only one call to friends or family every 30 days.i3 Legal and Social Visiting for Male Inmates MDC Brooklyn's regular attorney visiting hours are 8 a.m.-7:30 p.m. Monday through Friday and 8 a.m.-3 p.m. on weekends and holidays. There are no limits to the number of visits inmates can have with their attorney. MDC Brooklyn's regular social visiting hours are 12-3 p.m. and 5-7:30 p.m. each day. MDC Brooklyn assigns housing units a different day of the week for social visiting and allots each inmate one 1-hour social visit per week with up to four visitors. While BOP regulations state that "the Warden shall provide the opportunity for pretrial inmate-attomey visits on a seven-days-a-week basis," regulations also state that Wardens may restrict inmate visiting "when necessary to ensure the security and good order of the institution." 14 West Building Electrical System MDC Brooklyn's West Building receives a high-voltage electrical current from its electrical utility provider. The electrical current is delivered to three switchgears, each of which protects an electrical distribution panel by shutting off the electrical current in the event of a power surge. Once the electrical current is clear of the switchgear, it is delivered to electrical distribution panels, which distribute the current to different systems and equipment in the West Building. MDC Brooklyn labels its switchgears and electrical distribution panels as Priority 1, Priority 2, or Priority 3. Among other systems and equipment, the three electrical panels distribute electricity to: Priority 1: Priority 2: Emergency lighting throughout the West Building; heating, ventilation, and cooling (HVAC) equipment; fire alarms; security cameras; and electrical outlets used for medical and other life-safety equipment Emergency lighting throughout the West Building, electrically controlled doors and gates, other HVAC equipment, kitchen equipment, and unmonitored phones connecting to the Federal Defenders of New York Priority 3: Overhead lighting and electrical outlets in inmate cells and common areas, inmate phones, inmate computer systems, overhead lighting and electrical outlets in staff offices and common areas, and other kitchen equipment As discussed below, the fire at MDC Brooklyn in January 2019 destroyed the switchgear protecting the Priority 3 electrical panel, making it inoperable; the fire 13 14 See BOP Program Statement 5270.11. See 28 C.F.R. §§ 551.117 and 540.40 and BOP Program Statement 5267.09, Visiting Regulations. December 10, 2015. 4 EFTA00127751 did not damage or otherwise affect the Priority 1 or Priority 2 electrical panels, which control heat in the facility. The January 27 Fire, 7-day Power Outage, and Electrical Repair Photograph 1: Remains of Priority 3 Switchgear Source: OIG photograph, February 7, 2019 On Sunday, January 27, at approximately 12:55 p.m., MDC Brooklyn had an electrical fire in the West Building's mechanical room.15 According to BOP records, immediately upon discovery of the fire, MDC Brooklyn staff contacted the New York City Fire Department, which responded to the facility in less than 15 minutes and extinguished the fire. Several MDC Brooklyn staff members donned self- contained breathing apparatuses and gave fire department personnel access to the mechanical room. Although there were no serious injuries, some of the MDC Brooklyn staff members who responded to the fire were treated for smoke inhalation. By the evening of January 27, the MDC Brooklyn Facilities Manager and his staff determined that the fire had destroyed the switchgear protecting the Priority 3 electrical panel. Photograph 1 shows its fire-damaged remains. As a result of the damage to the switchgear, the Priority 3 electrical panel and its subordinate electrical systems and equipment could no longer receive electrical current. According to the Facilities Manager, the fire did not interrupt delivery of the electrical current to the building as a whole, nor did it damage the Priority 1 and 2 switchgears and electrical distribution panels.i6 Electrical systems and equipment powered by the Priority 1 and 2 electrical panels, such as HVAC equipment and outlets for most medical equipment, continued to operate normally. However, the medical x-ray machine in the West Building, which is powered by a circuit breaker supported by the Priority 3 electrical panel, was nonoperational. MDC Brooklyn maintains a second medical x-ray machine in the East Building, which was available for use by 16 As of the issuance of this report, the BOP has not determined the cause of the fire. 16 If a switchgear is damaged, an electrical current cannot be safely delivered to the corresponding electrical distribution panel. Therefore, even MDC Brooklyn's three backup generators could not provide an electrical current to the Priority 3 electrical distribution panel. 5 EFTA00127752 MDC Brooklyn staff if an inmate in the West Building required x-ray imaging. Additionally, the MDC Brooklyn Facilities Manager told us that, as designed, the HVAC system automatically turned off when the fire alarm was activated to prevent smoke from circulating throughout the building. We were further told that, as soon as it was deemed safe to do so, approximately 2-3 hours after the fire was extinguished, MDC Brooklyn facilities staff reactivated the HVAC system. Additionally, we were advised that emergency lighting in the West Building, which receives its electrical current from the Priority 1 electrical distribution panel, was activated when the Priority 3 panel (which controls cell and common area lighting) went down. In Figure 1, we provide a simplified diagram of the West Building electrical system and how the fire affected it. Figure 1 Simplified Diagram of MDC Brooklyn West Building Electrical System and the Effects of Fire Damage Priority 1 Power On Surveillance cameras Li HVAC equlpmen I. Outlets in medical exam rooms Fire alarms gap Emergency lighting Electrical dist lbutiOn panel • Switchgear Priority 2 Power On Staff and Automat C Federal doors Defender and gates phone lines F HVAC Kitchen equipment equipment Electrical distribution panel I Switchgear High-voltage electrical current 9 Cell and common area overhead lighting Kitchen equipment (I el Cell and staff area outlets Detainee phones for Detainee personal use computers Electrical distribution panel Switchgear Source: OIG, based on electrical repair documents and MDC Brooklyn facilities staff interviews After initially assessing the damage, MDC Brooklyn's Facilities Manager contacted a local electrical repair firm. The repair firm arrived at MDC Brooklyn the next morning, Monday, January 28. Together with MDC Brooklyn facilities staff, the repair firm further diagnosed the damage and developed a plan to restore electricity to the Priority 3 electrical systems and equipment. Specifically, the repair firm 6 EFTA00127753 Photograph 2: Temporary Priority 3 Switchgear Source: OIG photograph, February 7. 2019 determined that it needed to remove and replace the fire-damaged Priority 3 switchgear, wires connecting the utility- provided electrical current to the Priority 3 switchgear, and copper busses that distribute the electrical current from the Priority 3 switchgear to the Priority 3 electrical distribution panel. Before executing this plan, MDC Brooklyn hired a separate electrical engineering firm to determine the practicality and safety of the proposed repair plan. The engineering firm evaluated and approved the repair plan on Tuesday, January 29.t7 We were told that, throughout the rest of the week, the repair firm and MDC Brooklyn staff made repairs to restore electricity. According to MDC Brooklyn's Facilities Manager and the owner of the electrical repair firm, one of the more challenging tasks was sourcing and installing a replacement switchgear compatible with the facility's electrical system. As Photograph 2 shows, switchgears are large pieces of equipment. The Facilities Manager and the repair firm owner stated that this temporary switchgear needed to be disassembled to fit inside the facility, reassembled in the mechanical room, and then modified to integrate with MDC Brooklyn's electrical system. The MDC Brooklyn Facilities Manager and the repair firm owner told us that the electrical repair firm had almost completed its work by Saturday, February 2, but that it still needed to source one additional part before it could complete the repair and safely restore electricity. The repair firm owner and MDC Brooklyn staff did not anticipate that the firm would be able to source the part until suppliers 17 In a court declaration, the Facilities Manager explained that he was able to locate some spare circuits that received power from Priority 1 and Priority 2. He reprogrammed those circuits to provide additional lighting to certain areas, including medical treatment areas, food services areas, and the Receiving and Discharge areas (where inmates are searched before entering or leaving the building). The Facilities Manager explained that he could not use this method to restore power to all areas and all systems, including inmate cells, because there was not enough electrical amperage in the spare circuits to supply such a large power demand. Declaration at 4 and 5, Federal Defenders of New York. Inc. v. Federal Bureau of Prisons and Warden Herman Quay. 7 EFTA00127754 reopened for business on Monday, February 4. However, the repair firm owner told us that he sourced the necessary part over the weekend and restored power to the remaining Priority 3 systems, including overhead lighting for inmate cells and common areas, by 6 p.m. on Sunday, February 3.' Previous to the events that prompted this review and inspection, in early January 2019 MDC Brooklyn experienced another significant electrical issue resulting in a power disruption. We describe the issue in the text box. Previous MDC Brooklyn Electrical Issue According to the MDC Brooklyn Facilities Manager, on Friday, January 4, 2019, at approximately 6 a.m., a Priority 3 circuit breaker tripped, disrupting the electrical supply to the Priority 3 systems and equipment. Facilities staff members could not reset the circuit breaker; but, because there was no damage to the switchgear, they were able to use MDC Brooklyn's diesel generators to power the Priority 3 systems and equipment within 5 minutes of the power outage. However, at approximately 1 a.m. on Saturday, January 5, a generator malfunction cut off power to Priority 3 systems and equipment. By 5 p.m., MDC Brooklyn facilities staff were able to reset the tripped circuit and reestablish the electrical supply. The electrical repair firm, MDC Brooklyn's Facilities Manager, the Warden, and BOP Regional and Central Office facilities management staff all told us that they found no evidence to suggest that the circuit breaker and generator failures were related to the January 27 electrical fire. Sources: OIG interviews with the electrical repair firm owner, MDC Brooklyn's former Warden, MDC Brooklyn's Facilities Manager, and BOP Regional and Central Office facilities management staff and court testimony from the MDC Brooklyn Facilities Manager Prior OIG Work Related to MDC Brooklyn The OIG has conducted multiple investigations and reviews related to MDC Brooklyn. Below, we highlight some of the findings from our body of work: • In a recent criminal investigation, the OIG determined that, between 2013 and 2016, two Lieutenants and one Correctional Officer engaged in criminal sexual assaults against female inmates at MDC Brooklyn. As a result of the OIG's investigation, all three former MDC Brooklyn employees were indicted and eventually convicted, the most recent in 2019.19 • In our 2018 report on the BOP's management of its female inmate population, we reviewed the impact of the transfer of 366 female inmates from the BOP's Federal Correctional Institution Danbury facility to MDC Brooklyn. Even though MDC Brooklyn is intended for short-term confinement of pre-sentenced inmates, we found that some of the 366 low security sentenced female inmates remained at MDC Brooklyn for nearly 3 years. We found that MDC Brooklyn offered female inmates no access to outdoor space 18 The total cost of services provided by the repair firm was $58,948. 18 U.S. Attorney's Office for the Eastern District of New York, Press Release "Three Federal CorrectionaLafficAtS_Charged_with Sexually Abusing_Eemale Inmates," May 25, 2017, www.oig.justice.gov/press/2017/2017-05-25.pdf (accessed September 17, 2019). 8 EFTA00127755 and less natural light and fewer programming opportunities than would otherwise be available to female inmates at BOP facilities designed to house sentenced inmates in long-term confinement. 20 • In our 2015 report on MDC Brooklyn's management of its Special Programs Unit, we identified concerns with the BOP's placement of a particularly dangerous inmate in its Special Programs Unit with vulnerable inmates without implementing safeguards or providing guidance to correctional staff. We further found that MDC Brooklyn staff were not always aware of new security information or policies relevant to their work and that communication related to safety and security issues needed to be improved at the facility?' Scope and Methodology of the OIG Review and Inspection The OIG initiated this review and inspection to determine whether the BOP took appropriate steps to address issues caused by the fire and power outage, how those issues affected the conditions of confinement for inmates, and whether the BOP had in place adequate contingency plans for such an incident.22 We visited MDC Brooklyn on three different occasions, during which we toured the facility; tested air and water temperatures in housing units; reviewed surveillance video; and interviewed management staff, medical staff, correctional staff, and 11 inmates. We also interviewed relevant BOP Central Office personnel in Washington, D.C., including the then acting BOP Director and the BOP's public relations staff, as well as the BOP's Northeast Regional Director. Further, we interviewed an Attorney-in-Charge from the Federal Defenders of New York and a representative of the U.S. Attorney's Office for the Eastern District of New York, both of whom toured the facility during the week of January 27. Finally, Congresswoman Nydia Velazquez, whose Congressional District includes MDC Brooklyn, provided us with a statement detailing her experience touring the facility during the power outage. A more detailed description of the methodology of our review and inspection is in Appendix 1. 20 DOJ OIG Review of the Federal Bureau of Prisons' Management of Its Female Inmate Population Evaluation and Inspections Report 18-05 (September 2018), uwow.oig.justice.gov/reports/ 2018/e1805.pdf (accessed September 17, 2019). 21 DOJ OIG Management of the Special Programs Unit at the Federal Bureau of Prisons Metropolitan Detention Center in Brooklyn. New York, Evaluation and Inspections Report 15-08 (September 2015), www.oig.justice.gov/reports/2015/e1508.pdf (accessed September 17, 2019). 22 We did not assess the overall efficacy of medical care at MDC Brooklyn; however, we reviewed surveillance video footage to determine whether MDC Brooklyn staff delivered medication and insulin to housing units during the power outage. 9 EFTA00127756 TIMELINE OF MAJOR EVENTS AT MDC BROOKLYN, JANUARY 27-FEBRUARY 3, 2019 To help readers track the major events discussed in this report, we provide the timeline below. lire ORMISIMPOM Ina ••189.1 ft 12,3 p.m,aw,wlaela ROPY Wenders Jameneremaire Pea 6:00 tan MOO NmpoopMpsomm% SONY Court imp. The Nem met Timm iablePos arta* POMP (00601rd =MX Web. • I& mut. Mg pm mks about steam • ProteMCci•OPMPI to arts lacike Car a Walt* Plats • CO Minket, tommtliPapn an 1127 blot WI Put I/29 WEL NO Tip Pal 1„ 1 Sat V2 an V3 allipprot anon areas and 'we =lirtartraa0t meat ma& Rant. mimic d latIty wand due to •14, ate outipel and ratt‘tomml Ovesbancer 0, ex YOM.CM Olom T.-C-(41SO :F., 3 When three of the four passenger elevators at MDC Brooklyn are nonoperational, MDC Brooklyn secures inmates. Three of four elevators were nonoperational during the morning and afternoon of Friday, February 1. b MDC Brooklyn held visiting on the morning of February 3 but canceled it that afternoon because protestors had attempted to enter the facility. Sources: OIG Interviews with MDC Brooklyn staff, media reports, and MDC Brooklyn memoranda and emails 10 EFTA00127757 RESULTS OF THE REVEW The BOP Failed to Adequately Address Preexisting Heating and Cooling Issues at MDC Brooklyn, Resulting in Certain Inmate Housing Areas Being Below the BOP Target Temperature in January and February 2019 BOP policy sets a temperature target of 68 degrees Fahrenheit for its institutions during the winter. The policy also states that "occupants may experience a range of temperatures in their space that is a few degrees on either side of the targeted set point."23 Our review found that before, during, and after the January 27 fire, temperatures in MDC Brooklyn's West Building occasionally fell below the BOP's winter target temperature for periods of time, with the coldest recording being a 59 degree reading 1 week before the fire. We also found that temperature regulation issues at the facility resulted in winter temperatures in certain parts of the West Building far exceeding 68 degrees, including temperatures in excess of 80 degrees. MDC Brooklyn staff attributed these ongoing temperature regulation issues to the institution's HVAC system. Throughout the period of the power outage that occurred between Sunday, January 27, and Sunday, February 3, inmates, their attorneys, the public, and members of Congress expressed concern about heating conditions at MDC Brooklyn, particularly given the extremely cold temperatures in the New York City area that week.24 We found that during the power outage there were significant heating issues at MDC Brooklyn. However, we determined that these heating issues were unrelated to the fire and subsequent power outage, which, as noted above, did not affect MDC Brooklyn's heating systems. Rather, we concluded that long-standing unaddressed temperature regulation issues at MDC Brooklyn, combined with the extremely cold outdoor temperatures, caused temperatures in certain inmate housing units in MDC Brooklyn's West Building to drop below the BOP target of 68 degrees during the week of the power outage. We cannot, however, state with confidence how many inmate housing areas experienced temperatures at or below the BOP target temperature during the week 23 The BOP's Facilities Operations Manual. Program Statement 4200.12. provides: "Temperature set points will be targeted to 76 degrees Fahrenheit in the cooling season and 68 degrees Fahrenheit in the heating season. All spaces will be maintained as close to the targeted set point as possible. However, due to issues such as the age of the cooling and heating systems and the inability to control temperatures in individual spaces, occupants may experience a range of temperatures in their space that is a few degrees on either side of the targeted set point." The federal Occupational Safety and Health Administration views temperature and humidity conditions generally as "a matter of human comfort rather than hazards that could cause death or serious physical harm." However, similar to BOP standards, it recommends that indoor work place temperatures be in the range of 68-76 degrees. Richard E. Fairfax. Director, Directorate of Enforcement Programs, Occupational Safety and Health Administration, memorandum to Regional Administrators State Plan Designees, OSHA Policy on Indoor Air Quality: Office Temperature/Humidity and Environmental Smoke, February 24. 2003. 24 During the week of the power outage, outdoor daily low temperatures in New York City ranged between 2 and 33 degrees Fahrenheit. 11 EFTA00127758 of the power outage, or for how long, due to the absence of reliable temperature measuring methods at MDC Brooklyn. Thermostats in MDC Brooklyn's West Building do not show localized temperatures and do not centrally report temperature data to a computer system that can be remotely monitored. This is why MDC Brooklyn facilities staff must manually measure temperatures throughout the building, a process that can take between 2 and 4 hours, if they want to assess the facility's heating condition. In reviewing MDC Brooklyn's records, we found that facilities staff did not record temperature measurements during the first 3 days of the power outage and, for the 5 days (January 30—February 3) that staff did record temperature measurements, they did not always record measurements for every housing unit or record the time they took the measurements. Additionally, we found that measurements that MDC Brooklyn facilities staff did record before and during the power outage may be inaccurate because they did not use equipment appropriate to measure air temperature. 25 With these methodological deficiencies in mind, we found that available temperature logs for January 30—February 3 indicated that 8 of the West Building's 18 housing areas had at least 1 recorded temperature measurement below 68 degrees, with a lowest recorded temperature of 64 degrees. Many inmates housed in units experiencing these temperature regulation issues told the OIG that they were "freezing" or very cold during the week. Further, we found that environmental factors other than the ambient air temperature could have made inmates feel colder. For example, the institution's exterior cell walls, which abut inmate beds, can have surface temperatures well below the ambient air temperature. Differences in wall surface and ambient air temperatures were likely greatest when outdoor temperatures were in the single digits. We also found that the airflows out of the cell heating and cooling vents were at high speeds and, given the small size of cells, it would have been difficult for inmates to avoid exposure to fast-moving air that was below the target temperature. While these conditions were likely uncomfortable for all inmates in areas experiencing heating issues, they would have been particularly uncomfortable for inmates who did not have, or were unable to purchase from the commissary, cold-weather clothing prior to the onset of extreme cold weather. We determined that MDC Brooklyn's temperature issues were not isolated to the week of the power outage. In fact, MDC Brooklyn facilities staff have long struggled, and continue to struggle, to regulate temperatures in the West Building. Our review of historical data maintained by the facility indicates that certain inmate housing areas experienced temperatures below 68 degrees before and after the 25 Instead of using a tool designed to measure ambient air temperature, MDC Brooklyn facilities staff used an infrared laser thermometer that measures surface temperature. If, for example, facilities staff pointed the laser thermometer at a vent blowing hot air, the recording would reflect the surface temperature of the vent, which would likely be higher than the ambient air temperature. Conversely, if staff pointed the laser thermometer at an exterior wall or window, the recording may have been lower than the ambient air temperature. We found that, after the power outage, MDC Brooklyn acquired and began using a hygro-thermometer to test ambient air temperature. A hygro-thermometer is an appropriate tool to test ambient air temperature and humidity. 12 EFTA00127759 power outage. In fact, we found that a week before the power outage a mechanical issue caused temperatures in a housing unit to fall to 59 degrees. MDC Brooklyn temperature logs also indicated that building temperatures fluctuated greatly and that inmates were more likely to experience uncomfortably warm temperatures during the winter than cold temperatures due to the unevenness of the facility's heating system. BOP staff told us that they have struggled to regulate temperatures because MDC Brooklyn has not installed a Building Management System (BMS), which would continuously monitor building temperatures and HVAC equipment functionality. With live-temperature data, MDC Brooklyn management would be able to identify areas experiencing temperatures above or below the BOP target and could make adjustments to HVAC equipment much more quickly than their current manual method for temperature measurement allows. Temperature Logs for the Week of the Power Outage To assess temperatures in West Building inmate housing areas during the power outage, we reviewed all available MDC Brooklyn daily temperature logs, which covered Wednesday, January 30, through Sunday, February 3. The logs indicate that inmate housing areas averaged 70 degrees at the time of measurement. However, as we discussed earlier, the logs also indicate that 8 of the West Building's 18 housing areas had at least 1 recorded temperature measurement below 68 degrees. Because temperature logs provide only snapshot data about the temperature at the time of measurement, neither the BOP nor the OIG can use them to determine precisely how long temperatures were below the BOP target. Available data does, however, allow us to calculate the duration between an initial recorded measurement below 68 and the next recorded measurement equal to or greater than 68 (see Table 1 below). 13 EFTA00127760 Table 1 Housing Area Temperature Recordings Below 68 Degrees and Time Between Recordings, January 30—February 3, 2019 Floor-Unit Cell or Common Area BOP-recorded Temperature Time Between First Recording Below 68 and Next Recording Above 68 4-2 Cell 65 At least 60 hours Common Area 66.5 At least 60 hours 5-2 Cell 66 30 hours Common Area 66 52.5 hours 5-3 Common Area 67 22.5 hours 6-1 Common Area 66 22.5 hours 6-2 Cell 64 At least 60 hours Common Area 65.5 At least 60 hours 7-2 Common Area 65 30 hours 8-1 Common Area 66 22.5 hours 8-2 Common Area 65 22.5 hours Note: BOP-recorded temperatures are rounded to the nearest half degree. Source: MDC Brooklyn temperature logs As Table 1 shows, MDC Brooklyn staff recorded temperatures below 68 degrees most frequently in the "2-Unit" cells and common areas. This result is consistent with MDC Brooklyn staff testimony to the OIG that during cold-weather periods the 2-Units are generally more difficult to heat than the 1 and 3 Units because the 2-Units are the most exposed to winds from the Upper New York Bay. Temperature recordings also indicate that the 2-Unit on the sixth floor (Unit 6-2) had the greatest number of cold temperature readings during the week and the week's lowest recorded temperature of 64 degrees. Therefore, inmates in Unit 6-2 likely experienced cold temperatures for the longes