Internal Review for White Dr. and West Pensacola Street

Transcription

1 Internal Review White Dr. and West Pensacola St. Tallahassee, FL Director Timothy A. Lee Director Consolidated Dispatch Agency Leon County and the City of Tallahassee Page 1

2 Executive Summary As part of the internal processes of the CDA, the CDA Director initiated an internal review of the call taking and dispatching of the automobile accident occurring at the intersection of White Dr. and West Pensacola Street that occurred on September 6, at approximately 21:15 hours. The approach taken in the investigation included a thorough review of the entire initial call, interviews with supervisory staff and all staff involved, a detailed review of the dispatching software/hardware functionality during the processing of the call, and an overall validation if the proper policies and procedures were adhered to during the event. One purpose of the internal review was to verify that medical care to the victims was not delayed due to the original dispatch of EMS and Fire to an alternate location. Records indicate that EMS was on-site and providing treatment within three minutes and eleven seconds of the initial call. Though Fire had to be re-routed and arrived on scene within approximately ten minutes of the call, their absence did not delay the emergency medical care required. The internal review identified four specific findings which contributed to issues related to the call in question. To address these specific findings, five measures have been developed. Of these corrective measures, two have already been completed, two will be addressed in the short term, and one will be addressed in the short to long term In addition to the internal review of this specific call, multiple optional functionalities have been identified within the CAD system that will assist in the creation and cloning of calls. The conclusion of this report is that the CDA is working towards corrective measures that will reduce the potential of delayed responses to any incident. The CDA is focusing on CAD enhancements and ongoing training for CDA staff members. The CDA prides itself on being a professional organization with the focus on providing the highest quality of service to the first responders and the community that they protect. Unfortunately, with constant changes to technology and the human factor in the processing of approximately 500,000 calls annually, human factors may contribute to or cause a delayed response. The process of public safety dispatching necessitates utilizing each opportunity to improve on the CDA s established platform to prevent further occurrences of this nature. It is the CDA s goal that each of our employees operates error free. Due to the very complex computer system and human factors, we will continue to focus on ongoing refresher training and system analysis to promote the best quality of product. Page 2

3 Introduction On September 8,, two days after the incident, the Consolidated Dispatch Agency s (CDA) Director commissioned an internal review to be conducted regarding the incident at White Drive and West Pensacola Street that occurred on September 6,. On September 8, preliminary notification was provided to the CDA Board of the initiation of an internal review related to the incident. (Attachment 1) The review was initiated to evaluate the CDA s performance and response to the handling of the call for service for White Dr. and Pensacola St. on September 6,. The initial call came into the CDA at approximately 21:15 as an automobile accident with unknown injuries. Through additional information provided from the initial caller and various other callers, it was determined that the vehicles involved had airbag deployment prompting the dispatcher, pursuant to CDA protocol, to raise the priority of the call. The balance of the report is structured as follows: 1. Scope 2. Call Summary 3. Approach to Internal Review 4. Conclusion and Actions Taken 1. Scope Review all aspects of the call taking and dispatching process related to the White Dr. and West Pensacola Street incident with focus on the call cloning used on September 6,. Call cloning is a Computer Aided Dispatch (CAD) function that allows incident information (address, type of emergency, status of victims, etc.) initially intended for one agency to be replicated for the purpose of dispatching other agencies to the same location. Cloning allows the CDA to track a single incident even though each responding agency assigns a unique incident number for their internal tracking protocol 2. Call Summary On 6 September at 21:15:49 hours, the Consolidated Dispatch Agency received a call regarding a traffic crash with unknown injuries at the intersection of White Dr. and West Pensacola Street. The call-taker processed this call as a Priority 2 call for service for the Tallahassee Police Department (incident number PD/53237). At 21:16:00 the call-taker noted 2 vehicles involved and, at 21:16:16 airbag deployment. Within 29 seconds of the original entry, the incident was upgraded to Priority 1 (21:16:18). Additional information received by another call-taker indicated that everyone in both cars was unconscious. At 21:16:49 the original call-taker cloned an incorrect incident number (PD/52237) to Emergency Medical Services (EMS) and again at 21:17:05 to the Tallahassee Fire Department (TFD). The incorrect incident number referenced a call from the previous day that occurred in Northeast Tallahassee. As a result, EMS and TFD were initially dispatched to the wrong location (Village Square Boulevard). At 21:17:10 (twenty-one seconds after the original error was made) a third call-taker associated a call to incident PD/53237 and properly cloned the incident to EMS. This call-taker did not clone the incident to TFD. At 21:18:00 the original call-taker noted that an additional response required, and there is someone pinned. EMS arrived on-scene at the intersection of White Dr. and Page 3

4 West Pensacola Street at 21:19:00, which was three minutes and eleven seconds after the initial call was received. TPD arrived on scene at 21:20:34 (four minutes and forty-six seconds from the initial call). At 21:23:26 the incident was cloned to TFD. TFD was reported to have arrived on-scene at 21:25:51 (ten minutes and two seconds after the initial call). See Attachment #4 for a complete timeline of the incident. 3. Approach to Internal Review The internal review was conducted as follows: A. A comprehensive review of the Detailed Incident Report was performed. This included an examination of each agency s case summaries. B. An analysis of the audio recordings from each call associated with the incident has been completed. C. A one-on-one interview with Public Safety Communications Operator (PSCO) involved with the initial call was conducted. D. CDA s performance and response: 1. Review of employee training 2. Review technology 3. Review of specific employee actions 3.C.1. Review of technology Finding 1: A review of the CAD system indicates that the technology performed as specified. The clone function worked as designed. The information from the incorrect incident number was accurately replicated. 3.C.2. Review of employee training. Finding 2: adequate. The internal review determined that the CDA s employee training on cloning calls was Employee training cloning is included in the 40-hour Motorola PremierOne CAD Training (Attachment 2). It includes hands-on instruction on both the command line and right click cloning functionality. In addition, a Call Cloning quick reference guide was created to provide step-by-step instructions on the right click functionality method (Attachment 3). Neither Motorola nor the CDA requires a specific method to be used. The choice is made by user preference. 3.C.3. Review of specific employee action Finding 3: The call taker entered an incorrect digit while using the command line functionality to clone the incident number from law enforcement to emergency medical services (EMS) and fire. The call-taker was trained in CDA protocols as it relates to cloning incidents. As noted above, the employee entered an incorrect incident number. As a result, EMS and Fire were initially dispatched to the wrong location. 4. Determine whether command line clone functionality is a viable agency notification option as compared to the right click functionality. Page 4

5 Finding 4: The CDA internal review determined that both command line and right click clone functionality present equal exposure to human error. A review of the two methods used by call-takers to clone an incident was conducted. It was determined that the incident number to be cloned was incorrectly entered via the command line. The call-taker s entry was one digit off from the correct incident number. Consensus was reached that had the call-taker used the right click method there still may have been an error (e.g., whereby the wrong incident is highlighted and entered). Both methods present the potential for error. The CDA will be presenting the discussion to the Technical Sub-Committee for suggested enhancements or solutions. 5. Conclusion and Actions Taken A summary of the findings are: 1. The CDA s training program related to cloning functionality is provided to all employees through training. 2. A review of the CAD system indicates that the technology performed as specified. 3. The call-taker entered an incorrect incident number. As such, the CDA Director has taken the immediate following actions: 1. A written reprimand was issued to the call-taker. 2. The call-taker has undergone refresher training on the necessity of confirming CAD transactions when cloning an incident. To further minimize the potential for human error, the CDA has also proceeded with implementing the following action: 3. Motorola, the CAD vendor, has been directed to research and implement system enhancements that would minimize the potential for human error in utilizing cloning functionality as provided by the CAD (e.g., an auto-generated warning if a closed incident number is entered for cloning). 4. Development of a training curriculum that reinforces the importance of manually entering accurate information via the command line. 5. Review and revise the internal standard operating procedure that outlines the process for call classification and agency assignment (primary, secondary, and tertiary response). In particular, in response to traffic crashes where the status of injuries is unknown, if EMS is classified as the primary respondent, the CAD will auto-associate to Fire and Law Enforcement, thus eliminating the need to use the cloning function. Dispatchers will have the ability to cancel an agency s involvement in responding as additional information is made available. Page 5

6 Attachments: #1: Notification to the CDA Board of the initiation of an internal review #2: Motorola PremierOne CAD Training 40- hour lesson plan #3: Call Cloning quick reference guide #4: Timeline of 9/6/15 White Dr. and West Pensacola St incident Page 6

7 Attachment #1 Page 7

8 CONSOLIDATED DISPATCH AGENCY Tallahassee Leon County Florida To: From: Sheriff Mike Wood, CDA Board Anita Favors, City Manager, CDA Board Vince Long, County Administrator, CDA Board Timothy A. Lee Date: September 8 th, Subj. Update on White Dr. and Pensacola St. I wanted to take the opportunity to provide an overview and update on the CDA s response to the September 6 th 911 call and dispatching of resources to White Dr. and Pensacola St. It has been identified that at approximately 21:15:49 the Consolidated Dispatch Agency received a 911 call in reference to a vehicle accident at the intersection of White Dr. and Pensacola St. The initial caller could not advise if there were any injuries at the onset of the call. The initial call was dispatched to Tallahassee Police as an accident with unknown injuries. While still on the phone with the caller, it was identified that they could not validate air bag deployment, which would have raised the priority of the response. As part of the initial review it was identified that Tallahassee Police were immediately en route to the scene. Leon County EMS responded to the scene within three minutes, and Tallahassee Police responded within five minutes. Through the dispatch process, human error led to a delayed response from Tallahassee Fire. Preliminarily, the copying of the call was done improperly and Tallahassee Fire and Leon County EMS were sent to an incorrect location. However, due to the quick action of another call taker that copied the call, Leon County EMS response was unaffected. Tallahassee Fire arrived on scene from the closest available station within 10 minutes of the initial call. With the CDA processing approximately 500,000 calls per year it is our mission to insure public safety through coordination and collaboration. At this time, CDA administration will continue to analyze the particulars of the call dispatch. An after action report will be generated that will further improve dispatcher training and procedures. Respectfully Director Timothy Lee Page 8

9 Attachment #2 Page 9

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14 Attachment 3 Page 14

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16 Attachment 4 Page 16

17 21:15:49 Dispatcher 1 answered the call. The caller told the dispatcher that there had been a traffic crash with unknown injuries. Dispatcher 1 processed the call as a Priority 2 call to law enforcement because there had been no indication of injuries. Incident number PD/53237 was assigned. 21:16:00 Dispatcher 1 noted that two vehicles were involved in the traffic crash. 21:16:16 Dispatcher 1 noted that the airbags had deployed. 21:16:18 Dispatcher 1 upgraded the call to Priority 1 due to the potential for injuries based on confirmation that the airbags had deployed. 21:16:36 Dispatcher 2 received a call from another individual who stated that everyone in both cars was unconscious. 21:16:49 Dispatcher 1 attempted to clone the active incident. Due to making a key stroke error, an incorrect incident number (52237) was entered for cloning and information was associated from an incident that had closed-out the day before. As are result, Emergency Medical Services (EMS) and the Tallahassee Fire Department (TFD) received information in regard to 1400 Village Square Boulevard rather than the intersection of White Drive and West Pensacola Avenue. 21:16:51 Dispatcher 3 received a call from a third person who stated that four males involved in the incident were unconscious. 21:17:09 Dispatcher 3 received additional information that a hard side-swipe had occurred between two cars and that smoke was coming from both cars. 21:17:10 Dispatcher 4 correctly associated incident PD/53237 and cloned the information to EMS. The incident was not cloned to TFD. 21:17:16 TFD Engine 9 was dispatched to the incorrect location. 21:17:39 Dispatcher 5 dispatched Tallahassee Police Department (TPD) Unit P771 21:17:56 Dispatcher 5 issued a code to Unit P771 indicating that the call was urgent. 21:18:00 Dispatcher 1 added the following comments to the correct incident number: a. CAD Response: Delta (second highest level of response) b. Age unknown, gender unknown, consciousness unknown, breathing status unknown c. Multiple patients involved: 2 d. Dispatch Level: 29D04 (Pinned [trapped] victim) e. The incident involves multiple vehicles f. A multiple-unit response is required g. It s not known if chemicals or other hazards are involved h. There is someone pinned 21:18:55 Dispatcher 1 added additional scene comments 21:19:00 EMS arrived on the scene three minutes and eleven seconds after the initial call. 21:19:06 Additional comments report two people being trapped in a vehicle 21:19:08 TPD Unit P208 was dispatched 21:19:16 TPD Unit P368 was dispatched 21:19:28 An EMS Dispatcher associated the incident to secure another EMS Unit 21:19:33 An EMS Dispatcher associated the incident to secure a third EMS Unit 21:20:01 Additional comments indicate that people were trapped in the vehicle and not moving. Additionally, people outside of the vehicle were breaking the glass on the vehicles, presumed to gain access to the victims. 21:20:08 EMS advised TFD that extrication would be needed for a vehicle crash. 21:20:34 TPD reported to have arrived on scene. Unit P771 is confirmed as arriving at 21:20:41 Page 17

18 21:21:26 An EMS dispatcher associated the incident to secure a fourth EMS Unit. 21:21:57 TPD Unit P368 arrived on scene 21:22:09 TPD Unit P357 is dispatched to the scene 21:23:26 The correct incident is cloned to TFD 21:23:24 TFD Unit T4 self-dispatched upon hearing the change in the address of the incident location 21:23:42 Dispatcher 1 canceled TFD and EMS calls that were cloned in error 21:24:53 TPD Unit P581 is dispatched 21:25:51 TPD Unit P368 reports that TFD is arriving on scene Page 18