"Employee failure to follow established post orders provided the opportunity for this incident occur," the Texas Department of Criminal Justice report said.
Jerry Martin, 37, and John Ray Falk, 40, fled the prison, hijacked a car then were caught within hours. Martin was sentenced in 1997 to 50 years for attempted murder. Falk was serving life for murder in 1986.
According to the TDCJ report, Martin jumped into a Huntsville city truck and rammed it into Canfield. The horse threw the officer and she struck the truck's windshield before crashing to the ground, causing fatal head injuries.
The events were set in motion when a supervisory officer, Joe Jeffcoat, allowed Martin to improperly approach him after the prisoner asked that the officer hold his broken watch.
Then, according to the report, the following took place:
Jeffcoat, who also was on a horse, lost sight of Falk "contrary to established post orders." Then Falk created a noise that distracted Jeffcoat and Martin got close enough to Jeffcoat to rush the officer and get his gun. As Jeffcoat and Martin struggled, Falk joined in to try to get Jeffcoat off the horse.
Martin then got the officer's .357-caliber revolver and threw it to Falk, who pointed it at Jeffcoat. Jeffcoat stopped fighting and the two inmates then climbed over a barbed wire fence where Canfield was positioned on her horse in a parking lot. Falk began firing at her and she returned fire, as did several other officers. Falk then stuck Jeffcoat's revolver in Canfield's side and grabbed her rifle as Martin, who had jumped into the truck, rammed Canfield.
The investigation found the nine officers, including a sergeant, was the proper staffing level for the 76-prisoner work detail.
But the probe determined field Sgt. Larry Grissom should have ensured the view by officers on horseback was not obstructed by several heavy equipment vehicles that were nearby.
In addition, the investigators found the Walker County Sheriff's Department, the Huntsville Police Department and the prison system officers all were operating on different radio bands, meaning officers were relying on cell phones for communication. The team said the agency now was in the process of finding out what radio equipment would be best suited for communicating among agencies.
Jeffcoat was cited during a disciplinary hearing for failure to maintain constant control and surveillance of his work squad by allowing the inmates to work at an unsafe proximity to him and creating the situation that allowed Falk and Martin to overpower him.
Jeffcoat was recommended for dismissal during the hearing in October and requested an employee mediation, which was held last month. Agency spokeswoman Michelle Lyons said the outcome of the mediation was that Jeffcoat resigned, citing personal reasons.
After the escape, the inmates dumped the pickup about a mile away then confronted a woman in a bank drive-through and took her car. Huntsville police then shot out a tire in that car and the inmates ran away.
Falk was apprehended within an hour. Martin was caught hiding in a tree about 3 1/2 hours later. The next day, Martin unsuccessfully tried to hang himself in his cell.
Canfield, from New Waverly, had been a corrections officer for seven years. Her horse was shot in the gunfire and was euthanized. Canfield's death remains under investigation by the agency's Inspector General Office, the Texas Rangers and the Department of Public Safety.
