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DC 911’s own document again casts doubt on the agency’s official reporting of staff mistakes. The document is supposed to list all errors that hinder emergency operations, but it doesn’t. It’s missing most of the mistakes clearly documented last year by STATter911. The paperwork further backs up an earlier STATter911 report questioning 911 center data submitted to the DC Council. Before diving into those details, let’s first address some new mistakes and issues at DC 911.
OUC in the news
It was a rough ten days for DC 911. On Saturday (February 27), STATter911 reported a half-hour delay sending the right help to an injured Metro worker inside a tunnel. The incident appears to be another in a long series of communication breakdowns between DC’s Office of Unified Communications (OUC) and Metro. On Monday morning, a call-taker’s error only sent a fire engine — without an ambulance or paramedic unit — to a bicyclist struck and killed in Northeast DC. The man died. A few hours later, OUC couldn’t pin down the location of a pedestrian struck on I-66/Potomac Freeway. It took 14 minutes to get DC Fire & EMS to the critically injured person’s side. WTOP traffic reporter Dave Dildine was able to figure out the correct location about 10-minutes before DC 911.
Last Monday was also the day ABC7/WJLA-TV’s Lisa Fletcher aired a special report on the many problems facing DC 911. On Tuesday, WTOP Radio’s Neal Augenstein reported on the I-66 dispatching confusion and delays and FOX5/WTTG-TV reporter Evan Lambert broke the news about the wait for an ambulance after the bicyclist was struck.
New messaging from DC 911
But something else occurred Tuesday that’s important to acknowledge. It may be the first positive sign about DC 911 in a very long time. The messaging from the administration of Mayor Muriel Bowser suddenly changed. After many years of denials along with non and nonsensical answers by its recently departed director, someone finally confirmed what STATter911 has reported for a long time — there are serious problems inside OUC. That someone is Acting Deputy Mayor for Public Safety and Justice Chris Geldart. Geldart told Lisa Fletcher there are issues and vowed, “We’ll get better.”
Geldart is no stranger to OUC. He filled in for the better part of a year as its director in 2015. Geldart admitted the 911 center needs to improve and even confirmed the agency should be more transparent and accountable. The deputy mayor followed-up on that pledge the very next day when he confirmed an OUC mistake. A 911 call-taker entered wrong information about Monday’s deadly bicycle crash. It resulted in a five-minute delay dispatching an ambulance.
Geldart’s performance is dramatically different in tone than what we’ve long heard from DC officials. It’s refreshing. The deputy mayor also worked to build the public’s confidence in the 911 center.
While it was an impressive interview, I disagree with Geldart on some points. These include a claim of significant improvements at OUC since 2015’s L’Enfant Plaza Metro fire. OUC contributed to delays in getting help to trapped passengers. Among them, Carol Glover, who died. The evidence I’ve gathered doesn’t reflect the improvements Geldart is seeing — whether it’s responses to Metro emergencies or 911 calls in general.
Something else Deputy Mayor Geldart said caught my attention. It’s about OUC investigating ALL possible call-taker and dispatcher errors. According to Geldart, “… we do on every single time that we may have made a mistake, or we had a delay, even in minutes of getting the right address to our dispatchers, we go back and we review all those recordings.”
This may be the current policy under interim director Cleo Subido. It may even have been the policy under the previous director, Karima Holmes. But the reality is different. It appears OUC hasn’t been accurately reporting its mistakes to both the DC Council and the news media. There’s now more evidence DC 911 either hasn’t policed itself well or has purposely hidden mistakes.
As STATter911 first reported Thursday, an OUC document that’s supposed to cover all dispatching errors over 13 months only showed 24 confirmed mistakes out of 43 complaints. That’s very low for a 911 center handling about 1.8-million calls each year.
It’s an approximate error rate of fewer than two mistakes per month or one out of every 75-thousand 911 calls. For math geeks it’s .00133%. For context, in 2008 when a previous OUC director claimed an error rate about 7.5 times greater, current DC Council Chairman Phil Mendelson said, “… that sounds to me like a way of trying to cover up that there are too many mistakes.”
The document was released to the publication Communications Daily following a FOIA request. It was then shared with STATter911. OUC provided it in response to Communications Daily’s request for all FY20 dispatching errors and more specifically ones “that hindered emergency response”.
Anyone who regularly listens to DC Fire & EMS radio traffic can hear it for themselves: The number of dispatching errors — including many that hinder emergency operations — is significantly higher than documented by OUC. It’s routine to hear multiple mistakes in a single day.
Over the same time period covered by the complaint grid, I frequently monitored radio traffic. Thanks to OpenMHz.com, I have time stamped recordings of many incidents that are — without question — dispatching errors that didn’t make OUC’s list. In addition, there are scores of other mistakes where radio traffic alone doesn’t pinpoint fault. Despite STATter911 alerting OUC to all of these incidents, only a small number appear to have been investigated.
What’s missing from OUC’s list
At least 11 times last year 911 dispatchers let emergency traffic go unanswered for many minutes. As STATter911 first reported last week, it appears only four of those cases were investigated. Three urgent situations are among the seven missing from OUC’s own list: an ambulance crew attacked by a violent person; a request for paramedics after a patient went into cardiac arrest; and crews responding to a reported shooting, unable to determine if the scene was safe to enter.
The omissions extend beyond times dispatchers didn’t answer emergency radio channels. Many other types of 911 errors failed to make the list. Here’s a sample:
- 10/7/19 – Poor communications between OUC & Metro caused 18 minutes of delay and confusion after two trains collided.
- 10/14/19 – OUC so mishandled a response to a man who fell onto the rails at a Metro station, a fire officer dispatched to an unrelated call intervened in order to get the proper rescue assignment dispatched.
- 2/27/20 – OUC confused Warder Street and Water Street, sending DC Fire & EMS to the wrong location for a person having trouble breathing. (Note: STATter911 has documented OUC making this same mistake on multiple occasions.)
- 2/29/20 – OUC sent DC Fire & EMS to a reported cardiac arrest on Brandywine Street NW instead of Brandywine Street SE. (Note: This incident didn’t make the list even though OUC confirmed for reporter Evan Lambert it occurred because of a 911 call-taker’s mistake.)
- 3/4/20 – OUC failed to understand there are two locations where Florida Avenue & R Street intersect in Northwest and kept sending an ambulance to the wrong one. (Note: STATter911 has documented OUC making this same mistake on multiple occasions.)
- 3/10/20 – Dispatchers forgot about an ambulance crew that had been involved in a collision and failed to make the proper notifications. (Note: There was a similar incident where an ambulance crew was hit by a car being chased by police. In that one, OUC mistakenly sent help to a completely different incident. That error was on the list and investigated by OUC.)
- 3/28/20 – Dispatchers caused confusion when they dispatched extra equipment that wasn’t requested on a call where firefighters were already on the scene. (Note: STATter911 has documented OUC making this same mistake on multiple occasions.)
- 5/22/20 – OUC confused Anacostia Road and Anacostia Avenue in Northeast during a shooting call. (Note: STATter911 has documented OUC making this same mistake on multiple occasions.)
- 7/6/20 – Dispatchers sent DC Fire & EMS units to an EMS call that was obviously in Prince George’s County. (Note: STATter911 has documented OUC making this same mistake on multiple occasions.)
- 7/7/20 – OUC delayed sending help on an EMS call by dispatching a paramedic unit that was already on a another run. (Note: STATter911 has documented OUC making this same mistake on multiple occasions.)
- 7/7/20 – OUC dispatched DC Fire & EMS Truck 17 to the same downed tree seven different times.
- 8/5/20 – Within 60 seconds, OUC dispatched three different calls within 1000 feet of each other at the intersection of New York Avenue and Florida Avenue, NE. All were for the same person. OUC then dispatched it a fourth time eight minutes later. This tied up a fire engine, a ladder truck, two ambulances and two paramedic units. (Note: STATter911 has documented OUC mistakenly sending duplicate responses on scores of occasions. This occurs despite computer software designed to prevent this problem. Even though it ties up resources that may be needed for a real emergency, none of the many duplicate responses are listed as dispatching errors in OUC’s document.)
- 8/14/20 – OUC apparently forget to send paramedics requested by Ambulance 15.
- 9/2/20 – OUC dispatched a ladder truck to a wash down, despite the fact that DC Fire & EMS ladder trucks don’t pump water.
- 9/16/20 – OUC failed to alert a DC Fire & EMS engine company of an address change on an EMS call for a patient having chest pains. (Note: STATter911 has documented OUC making this same mistake on multiple occasions.)
OUC has consistently made the case that radio traffic alone doesn’t tell a complete story. Deputy Mayor Geldart made that same point during last week’s interview. But often, the rest of the story can only be gleaned from 911 calls — recordings OUC rarely releases. In other words, OUC complains about us not knowing information that only it can provide.
The interesting thing about the 15 incidents I’ve listed is this: You don’t need 911 calls or other information to confirm OUC made mistakes. Click any of the links above and you’ll hear it yourself. Whatever other information is behind the incident, it’s still quite obvious DC 911 staff made mistakes.
Most of the roughly 150 incidents STATter911 documented last year aren’t as clear as those 15 calls. In those cases, mistakes definitely occurred. We just don’t know who made them. Without the 911 calls, it’s hard to confirm if they were call-taker or caller errors. But remember, Chris Geldart’s expectation is ALL errors are investigated.
The information missing from the OUC document adds more support for my August report questioning the accuracy of data submitted to the DC Council. Every year, the Judiciary and Public Safety committee asks OUC for the number of “911 calls dispatched to the wrong location or for the wrong purpose”. It appears OUC hasn’t fully complied with that official request.
For all of FY19 OUC only reported three bad dispatches for DC Fire & EMS and one for DC Police. (Note: STATter911 is unable to monitor mistakes made in dispatching DC Police due to the encryption of police radio transmissions.)
My own research shows an unexplained dramatic increase in those numbers for FY20. STATter911 documented 32 DC Fire & EMS calls sent to the wrong address when the story was initially published in August (the complete list is here). That’s more than 10 times OUC’s report for the previous year. It’s also more than the total number submitted by OUC’s director for 2015 to 2020 combined.
Now, let’s go back to the new information in OUC’s complaint and investigation document. It covers the same period as my data gathering last year. The difference is OUC’s document only includes six of the 32 calls from my list of blown addresses.
We don’t know what caused these 32 bad dispatches, but there’s no question they occurred. You actually hear fire and EMS being sent to the wrong address in each case. Minutes later, you hear a new dispatch with the correct address. Despite this clear evidence, 26 blown addresses didn’t make this latest list provided by OUC.
OUC was asked about these discrepancies for the August report and still hasn’t commented. In fact, OUC hasn’t responded to any questions from STATter911 since February 25, 2020. The only response from DC officials has come when other reporters asked about my reporting (see below).
After the August story, former director Karima Holmes told WAMU’s Kojo Nnamdi, ” … it is abundantly clear that Dave Statter is making a concerted effort to fool the public into thinking there’s a systematic problem with D.C. 911.” She later added, “Dave Statter is not my oversight. I have our mayor. I have our deputy mayor, and we also have Council.”
Holmes and Mayor Bowser have both cast doubt on my reporting. What they haven’t done is provide specifics. They’ve never explained why the data on blown addresses provided to the DC Council is suspiciously low. In recent weeks, I’ve also asked for details on the new OUC complaint document. So far, no response. Holmes submitted her resignation in December and left OUC in January. She has been replaced, at least for the interim, by Subido.
OUC is currently being investigated by a contractor for the Office of the DC Auditor. The audit was spurred, at least in part, by STATter911’s reporting.
Next week is OUC”s oversight hearing before the DC Council. In preparation for that hearing, OUC answers the annual question about blown addresses. I look forward to this year’s answer.