POLK COUNTY, Fla - State investigators released their final report Friday regarding what happened the night teenage inmates took control of the Avon Park Youth Academy.
The 25-page report zeroes in on how quickly security and order at the facility collapsed last August.
Inspector Jeffrey McGuiness highlights how staff and policies are inadequate and calls for imminent change.
According to McGuiness, what staff at the academy needed was training, a practiced disturbance plan and sufficient leadership.
All of the issues were flagged as "critical deficiencies" that could have prevented the 60-plus teen riot.
In chronological order, the inspector picks apart the chaos.
The first issue discusses how staff did not initially call 911 because policy required them to first phone the fire department on the Air Force range. When dispatchers answered, staffers were instructed to call 911, leaving the teens fighting while staff was redirected.
Next there are scathing remarks regarding the lack of protection staff provided to the teen inmates. The inspector highlighted how 20 teens ganged up on a single teen and remarked how staff failed to stop it and chose not to intervene.
A radio call sent out during that time ordered only male staff members to try and break up the riot. Finally, administrators ordered all staff to back off as the riot spiraled out of control.
"There ain't nothing you can do. Stay out of it, we got the authorities coming," said an administrator recorded during the 911 call.
Once authorities arrived, inspectors agreed administration and staff failed again.
"There was a point during the incident when the staff acted on instruction from law enforcement to evacuate the facility," wrote McGuiness.
He added that those actions "created a significant dilemma" because regulations call for staff to protect the youth, not leave them unattended.
The report concluded by recommending staff and administrators train with the Polk County Sheriff's Office as well as review and update their riot and disturbance management plan.