In 2000, three janitors at the football building at Penn State saw Jerry Sandusky engaged in activities that one said he found more upsetting than the worst combat injuries he witnessed in the Korean War.
This janitor watched Sandusky pinning a young boy inside a locker-room shower and performing oral sex on him.
At the time, none of the janitors said anything to anyone.
Bringing bad PR to coach Joe Paterno "would have been like going against the President of the United States in my eyes. . . . Football runs this university," one worker told investigators this month as part of the independent report on the sex-abuse scandal at the university.
From the janitors to top administrators, the scathing report said Thursday, people at Pennsylvania State University kept silent about the crimes of Jerry Sandusky, sacrificing children out of fear for their jobs or damage to the university's "brand."
The inquiry, overseen by former FBI Director Louis Freeh, portrayed an already isolated campus in which Paterno and his allies operated inside the most walled-off fiefdom of all. At Penn State, the report said, "the Athletic Department was perceived as 'an island,' where staff members lived by their own rules."
While praising Penn State's commitment to academic excellence and the deep ties between community and school, the report described Happy Valley, as the locale is popularly known, as an insular place, convinced of its own righteousness.
"There is an overemphasis on 'The Penn State Way' as an approach to decision-making, a resistance to outside perspectives, and an excess focus on athletics," the report found.
At the top of the pyramid, of course, was Paterno, the unchallenged leader who embodied what the report called "a culture of reverence for the football program that is ingrained at all levels of the campus community."
With an annual compensation package estimated at $2.3 million - an amount Penn State fought to keep secret for years - Paterno earned more than twice the pay of the university president. He held sway over key university decisions, crucially including those involving discipline and his team.
The head of the Athletic Department was viewed by some as nothing more than Paterno's "errand boy," the Freeh report said.
In a telling example of "Paterno's excessive influence at the university," as the Freeh report put it, the university softened the punishment in 2007 when several football players waded into an off-campus party and ignited a brawl that left people seriously injured. University president Graham B. Spanier intervened to water down the players' punishment to make sure they didn't miss practice.
When campus police did learn of possible abuse by Sandusky, they hastened to keep the allegations under unusual wraps. In 1998, for instance, police kept one such report in an "administrative information" file, rather than labeling it as a crime.
During the investigation of this incident, the campus police chief at the time, Thomas Harmon, told top administrators that he had not made the allegation public, saying his department would "hold off on making any crime-log entry."
About the same time, Spanier acted aggressively against a sports agent who, before the 1997 Citrus Bowl, had bought $400 worth of clothes for a Penn State football player.
"Spanier was very aggressive in that case and banned the agent from campus," according to the report, which quoted the university president as saying the agent "fooled around with the integrity of the university, and I won't stand for that."
Among many reform recommendations, the Freeh inquiry said Penn State should appoint a university ethics officer to advise the president and board, as well as bring in new board members less tied to the university.
It also said Penn State should elevate the Human Resources administrator's job in status and clout; improve background checks; eliminate any favoritism in student discipline; and greatly improve compliance with a key federal law requiring universities to keep track of sexual assaults.
Lawyer Marci Hamilton, an expert on sexual abuse and the law, said that part of Penn State's problems reflected "the deification of Joe Paterno," idolatry that she said meant his decisions went unquestioned.
Still, she said, Penn State was hardly unique.
"We've seen this in a number of other situations," said Hamilton, who helped advise the Philadelphia District Attorney's Office in its probe of sexual abuse within the Philadelphia Archdiocese. "It's not the first time you have a closed community, and sexual abuse of children gets perpetrated."
She said the one-two punch of the Penn State scandal and the Philadelphia D.A.'s investigation - Sandusky and a Philadelphia monsignor, William J. Lynn, were convicted on the same day last month - may spur reform to ensure that institutions don't "protect their self-image at the expense of children."
In a news conference after the release of his report, Freeh said he was struck by the silence of Penn State's janitors.
"They were afraid to take on the football program. They said the university would circle around it," he said. "If that's the culture at the bottom, then God help the culture at the top."