Investigators have determined that a 911 center fire dispatcher error led to the deaths of a husband and wife in Waukesha, WI last month.
Originally officials stated that a software malfunction caused the fire department delayed response. But now after a very detailed and in-depth investigation, the delay was due to human error in the Waukesha City Communications Center.
Investigators released their findings today in a 284-page report which is below.
BRIEF DETAILS:
An initial 911 call was made at 1:25:06 a.m. on March 8 with police responding first, however the first engine arrived on the scene 11 minutes after that call.
-There were some technical issues. The investigative review showed there was no error on behalf of US Digital’s station alerting software. The error stemmed from the ProPhoenix CAD software.
-Multiple policies and protocols were not properly followed or not followed at all.
-The most glaring was that the fire dispatcher failed to manually activate station alerting within one minute of the fire call being entered in the CAD system.
-The fire dispatcher entered the call code into a police dispatching field rather than a fire dispatching field.
-The dispatcher failed to ensure the fire department personnel had acknowledged the run.
-Ensuring the FD acknowledges the call and are responding is the primary base function for this fire dispatching position.
-There was no error in the alerting software.
-The fire dispatcher also did not immediately upgrade the fire when requested.
-There was not a dispatch center supervisor on duty at the time.
-An internal investigation is ongoing that could result in disciplinary action against the fire dispatcher, who remains on administrative leave.
This report is among several documents that can/should be used as a template in a “could that happen here?” review by fire leadership working with communication center leadership.
COMMENT: On numerous recent occasions across North America, challenges related to 911/fire communication recruitment, compensation, clear/simple policy, initial and on-going training along with qualified supervision in an environment of discipline focused on FIRE DEPARTMENT operations-using equipment that matches the need*, have been identified and factors in failures.
(*too often CAD systems are purchased that are incapable of assuring the fastest dispatching of fire emergencies. While most police incidents require numerous questions and are not “in progress”-most fire and EMS responses are “in progress” and require a much streamlined process of “getting the tones out.”)
INVESTIGATION REPORT:
Take Care. Be Careful. Pass It On.