Fatal Queens fire revealed flaws in dispatch system, city investigation showed

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Jim Hoffer investigates. (WABC)

The response to a fire that killed two Queens children in April was delayed by a flawed dispatch system, city investigators concluded Tuesday.

"The baby is not breathing!" yelled one fire fighter as they waited desperately last Easter morning, April 19, for an ambulance to arrive.

Firemen were trying to resuscitate Jai' Launi Tinglin and Aniya Tinglin, both 4, whom they had pulled out of the burning Queens home.

They waited 21 minutes for EMS to arrive, by then it was too late.

The findings by a Department of Investigation probe blame a series of human errors and miscommunications for the delay in medical help.

The report concludes the city's 911 system is unacceptably flawed.

"We've got an outdated overly complex system," said Mark Peters, DIO Commissioner.

Department of Investigations Commissioner says the 911 system was set up to fail, so inefficient that it required seven different dispatchers to get an ambulance to the fatal fire or any fire.

"In this system by requiring so many different people and so many different steps actually increased the possibility of human error rather than reduce it," Peters said.

Among those errors, two workers at the call center were not at their desks, another dispatcher thought EMS had already been notified.

The new fire commissioner responded to the problems highlighted in the report saying they're being fixed.

"We've made changes in the procedures, right now our fire dispatchers call EMS first to request an ambulance. We've made technical changes. We put ATS terminals on EMS side so they get an automatic notification," said Daniel Nigro, the FDNY Commissioner.

Some of these problems are the legacy of former Mayor Bloomberg's long-delayed, wildly over-budget, new 911 system which has yet to be fully implemented, perhaps in two years.

The city's Head of Investigations says we have to learn from the loss of last April's fire.

"It took way too long to get an ambulance there and that's something we have to fix," Peters said.

After the deaths of the two children, the community rallied around the family, raising money for funeral services and starting a college fund for Jai' Launi's twin sister, who was hurt in the fire.

Authorities said the fire was started by children playing with fire.

On Tuesday, the DOI recommended several action to streamline the emergency response process.

Here is the full DOI report:

The investigation did not find criminal wrongdoing but determined that there are systemic problems with the City's system for dispatching an ambulance to the scene of an active fire.

Specifically:

-The system for dispatching an ambulance to a fire scene requires multiple staff to take multiple steps, increasing the possibility of error and delay.
-Poor supervision of the dispatch staff contributed to the errors in responding to the fire that occurred on April 19-20, 2014, including the mistaken belief by one dispatcher that another had notified EMS of the need to dispatch an ambulance, and the failure to take steps to reassign or retrain a dispatcher with a history of mistakes.
-The City's bifurcated computer-aided dispatch system does not allow FDNY and EMS dispatchers to efficiently share critical information, such as the borough where a fire is occurring, so EMS dispatchers typically must wait until they receive a telephone call from a FDNY dispatcher to dispatch an ambulance.

DOI recommended the FDNY take several steps to immediately address these problems, specifically:

1. Streamline the dispatch process as much as possible within the current technological constraints of the system, and eliminate some steps so a shorter process can be implemented. FDNY has begun to tighten the dispatch process, including by making EMS the first of the two-step notification process, rather than dispatchers reaching out first to an FDNY Deputy Chief.

2. Improve supervision of dispatchers, including scheduling meal breaks and one-to-one relief at Fire Dispatch Central Offices and enforcing FDNY policy regarding the unauthorized use of technology while on duty to ensure that dispatchers are not distracted while they are working. FDNY must better train and manage its supervisors, since in this incident, FDNY leadership was put on notice regarding a dispatcher's skill deficiencies and failed to take any steps.

3. Take immediate steps to enhance communication between the Fire and EMS computer-aided dispatch systems. While the City has undertaken a large-scale project to integrate emergency response, the Emergency Communications Transformation Project, the FDNY must not wait until the completion of that project to address the problems outlined in the Report. To that end, in response to DOI's recommendation, the FDNY has studied the issue and has come up with an interim solution to link the computer-aided dispatch system used by the FDNY with the computer-aided dispatch system used by EMS, which will take up to six months to implement; and a short-term fix, already implemented, that allows EMS dispatchers to view a hard-copy printout of complete information regarding an active fire and then manually enter information into their dispatch system to dispatch an ambulance. DOI notes that while this is an improvement, it still requires a dispatcher to monitor a teleprinter while at their workstation. DOI recommends that FDNY develop additional solutions to further simplify the process.

Commissioner Peters thanked FDNY Commissioner Daniel A. Nigro and Anne Roest, Commissioner of the City Department of Information Technology & Telecommunications, and their staffs, for their assistance in this investigation.

The investigation was conducted by DOI's Office of the Inspector General for the FDNY, including Counsel to the Inspector General Adam Libove and Assistant Inspector General Kate Zdrojeski under the supervision of Inspectors General Shannon Manigault and John Tseng and Associate Commissioner Paul Cronin.


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