U.S. Penitentiary Atwater and the Federal Bureau of Prisons failed to take several steps that might have prevented the murder of correctional officer Jose Rivera, according to a Department of Justice report.

The report, obtained by the Sun-Star on Monday, reveals disturbing new details about the circumstances surrounding Rivera's murder and what appears to have been standard operating procedure at USP Atwater at the time of his death.

It says the two inmates accused of killing Rivera, James Leon Guerrero and Joseph Cabrera Sablan, were drunk when they allegedly stabbed him to death last June, and that alcohol was widely available inside the penitentiary. It says the handmade, ice pick-like weapon used to kill Rivera was probably fashioned from parts of a cafeteria dishwasher, and that a previous internal investigation had warned of earlier uses of dishwasher parts to assault USP Atwater correctional officers.

The report also says no one else working near Rivera had keys to the housing unit where he was killed, which prevented the earliest responders from reaching him. They instead stood helplessly by, waiting for keys while Rivera's attackers continued to stab him.

The Sun-Star has previously reported that Rivera, a 22-year-old Navy veteran, was alone with more than 100 inmates when he died. In line with policy, he was wearing no protective equipment and carrying no weapons. He had worked at USP Atwater, a high-security prison just outside Merced, for less than a year.

Rivera's family plans to file a wrongful death lawsuit in federal court today against the Bureau of Prisons, said Mark Peacock, the family's Newport Beach-based attorney.

"The bureau basically set this poor guy up," Peacock said of Rivera. "His mother deserves answers as to why things were ever allowed to get this bad, and she's not getting any."

A Bureau of Prisons spokeswoman, Traci Billingsley, said the Department of Justice report is not a public document and therefore declined to comment on it. USP Atwater's spokesman couldn't be reached Monday.

Though Rivera's alleged attackers were not asked to submit to blood, breath or urine tests, video surveillance footage and interviews with witnesses indicate they were drunk at the time of Rivera's murder, the report says.

"Intoxicants are easily obtained by the inmate population at USP Atwater," it states.

The report adds that inmates often aren't punished for making, selling or drinking alcohol and that drunk inmates have attacked correctional officers at USP Atwater in the past. The report also says inmates caught with weapons often aren't punished and that weapon searches aren't adequate.

It says that eight months before Rivera's murder, inmates living in the same housing unit as the two accused of his murder were found to have taken steel rods from the cafeteria's dishwasher, which they used to make a weapon and take a correctional officer hostage.

An investigation following that incident warned that steps should be taken to prevent dishwasher parts from being used as weapons again.

"Several repairs were made to the dishwasher in Food Services to replace stainless steel rods from the conveyor belt," the Department of Justice report says. "However, this area was never identified as a source of weapons material with appropriate controls to restrict inmates from removing parts for the purpose of making weapons. This was noted in the After Action Report" following the hostage situation.

The investigation into the hostage incident also revealed that cell assignments are controlled by gangs inside the prison, rather than by USP Atwater employees, the Department of Justice report says.

It states that both of Rivera's alleged attackers had histories of assaulting correctional officers, though only one of them, Sablan, had been designated a high-risk inmate. The report also says Guerrero was living in a cell to which he was not assigned.

Citing autopsy results, the report says Rivera was stabbed at least 28 times. One wound punctured his heart, causing him to bleed to death.

Sometime during the assault Rivera hit his body alarm, sending a signal to other correctional officers to respond. The report says the first two people to arrive at the scene of the attack, a secretary and a unit manager, came from offices inside Rivera's housing unit. They did not try to physically intervene.

Neither they nor the next several responders had keys to the unit's front door, which delayed other correctional officers in stopping the attack.

"This delay ... could have been reduced had any of the other unit staff had a key to the front door," the report states. "It appears from reviewing the tape, Officer Rivera is stabbed at least 10 times before the first staff member arrives on the scene. There appear to be at least another seven stabbings before the mass staff respond to the emergency."

Among its recommendations, the report calls for new procedures for assigning inmates to cells, improved training and more measures to find and seize intoxicants and weapons.

"It's a shocking dose of reality as to what these brave souls have to deal with at work," said Andy Krotik, spokesman for the Atwater-based Friends and Family of Correctional Officers. "They're obviously not being given the tools they need for the job."

The Federal Bureau of Prisons, of which USP Atwater is a part, is overseen by the Department of Justice. The department's report was written by a team of bureau employees assigned to investigate the circumstances surrounding Rivera's death. Though the team's on-site examination concluded last July, the report is dated April 17, 2009.

The Sun-Star obtained it Monday.

National union leaders who represent federal correctional workers said they didn't see the report until late last week.

"It kind of makes you wonder why this thing took so long to come out," said Bryan Lowry, president of the Council of Prison Locals of the American Federation of Government Employees. "It's certainly not something to be proud of."

Lowry said there have been some improvements at USP Atwater since Rivera's death but that many of the problems highlighted in the report still exist at Atwater and other federal prisons.

"For the most part, the control and supervision of inmates is still out of control," he said. "We're still drastically understaffed and our officers are still out there completely unarmed."

Lowry said union leaders have been pressing the Bureau of Prisons to allow correctional officers to carry nonlethal weapons, such as batons or Tasers, since before Rivera's death.

"Every issue that you see brought up in that report -- and other ones, too -- we've been bringing up those dangers for a very long time," Lowry said. "We'll never know, but it's my belief that if Jose Rivera had been allowed to carry a 15-ounce can of pepper spray, he'd probably be alive today."

In the wake of Rivera's death, USP Atwater's warden was replaced and the Bureau of Prisons has begun supplying stab-resistant vests to employees who want them.

Guerrero and Sablan were charged with first-degree murder in August and could face the death penalty if they're convicted.

USP Atwater opened in 2001 and housed roughly 1,100 prisoners at the time of Rivera's death. Systemwide, the Federal Bureau of Prisons oversees more than 200,000 inmates.

The third of five children, Rivera lived in Chowchilla and graduated from Le Grand High School in 2003. He enlisted in the U.S. Navy shortly after and served four years in the military, including two tours in Iraq.