Sheriff Jack Crabtree said human error was to blame for Yamhill County Jail inmate Andrew Webb's Aug. 19 escape, saying it should never have occurred and promising steps to avoid any repeat.

New policies and procedures are being implemented, equipment is being augmented or upgraded and personnel changes are being made, Crabtree said. He said the moves are designed to ensure the safe transfer of inmates to and from the courthouse and jail in the future.

The escape occurred as retired Newberg-Dundee police officer Art Pohl, serving as a reserve officer with the sheriff's office, was returning Webb to jail by wheelchair following proceedings on a probation violation that netted him 15 months. When the sheriff informed him he was being relieved of prisoner transport duty, Pohl resigned, declining reassignment.

Crabtree said he could find no justification whatsoever for Webb escaping.

He said an inmate should never elude a transport deputy. The possibility of the inmate jumping out of the chair and taking off should have been anticipated.

"This boils down to, when the guy bolted, within 10 or 15 feet, he should have been taken down to the ground," the sheriff said. "Then this never would have been an issue.

"It would have been an attempted escape. The guy did something stupid by trying to run and he got tackled."

Crabtree said, "We give no one the benefit of the doubt when he is a prisoner. We don't assume he will do the right thing. We assume he will do the wrong thing.

"That's why this is so shocking. How could this happen?"

Capt. Ron Huber, the county's jail commander, launched an internal inquiry Sept. 2 with Capt. Ken Summers and Sgts. Jason Mosiman and Tim Svenson. Individuals involved with the incident were interviewed, videotape was examined and evidence was collected to develop a criminal case against Webb.

Eventually, Huber and Moisman developed a set of recommendations aimed at preventing a future escape, and they met with Crabtree's approval. They are designed to address the following mistakes and deficiencies identified by the task force:

- In his original radio call, Pohl said, "I have an inmate who is running. He just went running around the courthouse." Because the call included nothing more specific than location, most initial responders headed the wrong way.

Huber, attending a joint jail and patrol supervisors meeting at the time, said, "I remember saying, 'We had an inmate in a wheelchair just escape from our court security deputy. He is heading around the courthouse.'"

He said, "This caused the patrol supervisors to head out the doors, almost all going in the wrong direction."

- Several patrol sergeants didn't have radios with them. And some jail officers carried radios not capable of communicating with patrol officers, officers from other agencies or 911 dispatch personnel.

"Valuable time was lost in the initial stages of the search because of poor communication and lack of appropriate communication tools," the task force concluded.

- Webb was being escorted by a lone reserve officer.

In the future, at least one armed deputy will be assigned to wheelchair inmates. And two armed officers will be assigned when the inmate is considered an escape risk.

- Webb was not sufficiently restrained, as he had not been placed in leg irons.

In the future, Crabtree said, jail personnel will err on the side of safety. Even inmates confined to a wheelchair will be fully restrained, as it is difficult to tell when an illness or injury is being faked.

To implement that, he said, the office has acquired 24 more sets of leg irons. He said it has also acquired six so-called "black boxes," used to cover handcuffs when tighter security seems warranted for a particular inmate.

New jail policy requires that all inmates being transferred from one location to another outside the jail itself be secured three ways - with leg irons, belly chains and handcuffs, used in combination.

Sets of leg irons will be stored in the bullpen, a holding area for inmates who awaiting court appearances, for that purpose.

Crabtree said, "There was some fabrication about his health," Crabtree said. "He saw medical staff, but if someone says, 'I can't walk to court,' you give them a wheelchair.

"Can you imagine what the story would look like if an inmate said, 'I can't walk to court,' and we said, 'Too bad, you're walking anyway? We don't believe you.' And then it turns out there was something wrong."

He said denying an inmate a wheelchair isn't the answer. Better security is.

"We have made changes that hopefully ensure, although nothing is guaranteed, that this won't ever happen again," the sheriff said. "When something like this happens, it heightens everyone's awareness. If there was some complacency going on, it's not going on any more."

When Webb arrived at the jail from the Multnomah County Justice Center in downtown Portland, he told jail officers he had hurt his back in a fall in Portland. Unbeknownst to them, he apparently made up the story with escape on his mind.

When Pohl wheeled Webb out of the courtroom in mid-afternoon, they got into an elevator and descended to the lobby. From there, the deputy wheeled Webb through a handicapped access door and down a handicapped access ramp on the Fifth Street side of the complex.

Near the flagpole, Webb slipped out of one of his jail-issued flip-flops. When Pohl reached down to pick it up, the inmate leaped from the chair and took off.

Webb quickly outdistanced the deputy, despite being handcuffed, belly-chained and barefoot, fleeing east toward Galloway Street in standard-issue prison blues. He was soon out of sight.

At the time, Huber, Summers, Mosiman and Svenson were in a management meeting with jail sergeants John Hausman, Woody Little, David Lux and Michael Saunders, patrol sergeants Brandon Bowdle, Steve Warden and Russ Vandwettering, and jail administrative assistant Carol Rogers. Huber interrupted the meeting to sound the alarm, then relayed the word to Crabtree.

"I was shocked," the sheriff said. "The first thing I asked was, 'How could this have happened?'"

A command post and perimeter were quickly established.

At the peak of the search, 30 vehicles, 50 officers and a helicopter were involved. The McMinnville, Newberg and Yamhill police departments joined in, as did the Oregon State Police and U.S. Marshal's Service.

However, as soon as he got out of sight, Webb had stolen a car and headed to Portland. He was long gone during most of the search effort.

Webb was apprehended two days later in eastern Multnomah County.

He and a companion stole some beer at a Troutdale truck stop, and employees gave chase. They got a description and plate number for the getaway car, which was on a police hot list.

After leading Multnomah County sheriff's deputies on a high-speed chase, they dumped their stolen car and Webb leaped into the Sandy River at Lewis and Clark State Park, east of Troutdale off Interstate 84.

Deputies were joined by Gresham and Troutdale police officers in retrieving Webb from the river with a boat. They found him hiding in a mid-river logjam backed up behind a rail bridge support.

After undergoing treatment for minor injuries, he was booked into the downtown Portland Justice Center on one count each of attempt to elude a police officer, possession of burglary tools and unauthorized use of a motor vehicle.

While in custody, he allegedly assaulted a corrections officer. That led to additional charges of fourth-degree assault and assaulting a public safety officer.

Meanwhile, he has a 15-month sentence to serve in Yamhill County for violating probation on an earlier conviction. And he is facing serious felony charges in Washington's Klickitat County that could net him a long prison term.