The incident occurred because of a breakdown in adherence to established procedure and acceptable correctional practices. It had become the practice of staff to leave security doors opened. Additionally, some security features such as the glass in the control room were inadequate. These problems and deficiencies, in combination, allowed what should have been a minor inmate-on-staff assault to escalate into a major disturbance encompassing the entire unit and including the taking of hostages and injuries to officers. It was concluded that a reasonable judgment was made in not attempting to end this incident by assaulting the unit. The primary and appropriate concern was to prevent loss of life. The decision to negotiate with the inmates achieved this goal. Negotiators and members of the Crisis Intervention Unit did an excellent job in bringing this incident to a conclusion.