NY Daily News – October 22, 2014
by Erik Badia, Greg B. Smith
It took 21 minutes for an ambulance to respond to a Queens fire that killed two helpless 4-year-olds — a delay caused by a stunning combination of human error and tragic flaws in the Fire Department’s dispatch system. A damning report released Tuesday by the city Department of Investigation detailed a “highly cumbersome” system that actually encouraged mistakes. Beginning the night of April 19 — the day before Easter — there were plenty of mishaps to go around.
Investigators found that at a dispatch center on Woodside Ave. in Queens dispatchers weren’t at their desks and one assumed the other had sent out an ambulance to an “active fire” on Bay 30th St. in Far Rockaway.
When the smoke cleared on Bay 30th, Jai’Launi Tinglin and his half sister, Ayina Tinglin, were dead. On Tuesday, their great-grandmother Estella Jackson Bernard stood near the gutted home and said the DOI report was “no consolation.”
“It’s only bringing grieving,” she said. “I’m very, very upset about it, because the children would be alive. . . . They would not have died if the ambulance was here.”
She wanted someone held responsible.
“What happened?” she asked. “Who is to be blamed for this?”
DOI Commissioner Mark Peters said his agency’s four-month probe “exposed an antiquated, unwieldly system for dispatching ambulances to the scene of an active fire that substantially increases the opportunity for human error.”
In its 21-page report, the DOI implicated no individual in potential criminal wrongdoing, but laid out a devastating chronology starting when the initial call came at 11:51 p.m. on Saturday through the arrival of an ambulance at the scene at 12:12 a.m. on Easter Sunday.
In the excruciating minutes in between, no fewer than seven individuals were involved in passing the call from the NYPD to the FDNY and finally to EMS, the report found.
The DOI singled out a serious communication breakdown between two FDNY employees in particular: Dispatcher Kathleen Valentine and her supervisor, Jacquelin Jones.
Valentine had been red-flagged earlier for “dispatch-related issues.” Three months before, one supervisor expressed concern that she would be “a liability” if she was allowed to remain on the job.
Jones had also been disciplined months earlier for failing to properly supervise dispatchers on her watch — including Valentine.
That night at the Woodside Ave. dispatch center two of the usual six employees had stepped away from the desk when the call arrived. That meant dispatchers were MIA at “crucial moments,” the report charged.
Fire trucks arrived within five minutes. At the scene, a battalion chief radioed back that there were people trapped, but Valentine did not enter that into the system or request EMS.
Valentine later told investigators a prompt that would have reminded her to notify EMS did not pop up on her computer screen, so she “assumed” another dispatcher had handled that task.
Several minutes later, the frustrated battalion chief demanded an ambulance at the scene. According to tapes of the communications between the agencies reviewed by the DOI, Valentine for the first time called up the EMS dispatchers.
To her surprise, the EMS dispatcher asked, “Did you guys give us Bay 30th St.?”
Valentine then apparently turned to a co-worker and asked, “Did we ever get in touch with EMS on that fire?”
The co-worker responded, “No idea. I didn’t call them.”
The DOI also heard a “chirp” during one of the calls indicating Valentine had a cell phone at the dispatch desk. Cell phones are barred from all operations areas.
Valentine admitted she had a phone, but insisted it was in her purse.
An ambulance was finally dispatched at 12:06 a.m. on Sunday — more than 15 minutes after the first 911 call came in. The ambulance arrived at the scene at 12:12 a.m. — 21 minutes after the initial call.
The DOI also blamed the city’s bifurcated computer-aided dispatch system that prevents FDNY and EMS dispatchers from sharing “critical information,” including the borough where the fire has erupted. That means EMS dispatchers often have to wait for a phone call from the FDNY before dispatching an ambulance.
And the DOI found the FDNY’s dispatch system is undermined by “outdated technology” that requires FDNY dispatchers to call the EMS. They called for a system upgrade that would automatically notify the EMS of all active fires.
Fire officials said Tuesday that supervisor Jones and dispatcher Valentine remain on modified duty and now face possible disciplinary action. They had previously been suspended without pay for 30 days.
The FDNY said it had upgraded the system since the Far Rockaway fire and following delays in responding when 4-year-old Ariel Russo was fatally struck by a car on the Upper West Side in June 2013.
“Our goal is to do the best job possible on every emergency call we handle, and that’s the standard I expect of everyone involved — including our dispatchers,” Fire Commissioner Daniel Nigro said. “We’ve implemented several procedural changes and are investing in technology to make certain that there’s no delay sending ambulances to fires.”
In 2012, the FDNY requested $200,000 to temporarily upgrade the dispatch system so the EMS is automatically notified on all active fires. Then-Mayor Michael Bloomberg’s budget czar shot down the request because the city was already spending millions to upgrade the entire 911 system.
That overall upgrade is way behind schedule. It won’t be finished until 2016. Fire officials expect to request funding for the temporary upgrade in the coming weeks.
City Councilman Donovan Richards, whose district includes Far Rockaway, said the system needs to be upgraded now.
“We hope they take these recommendations and make them real,” he said. “When there’s a fire, an ambulance should automatically be dispatched to the scene. Every second counts.”
A spokesman for Mayor de Blasio, Phil Walzak, said the system needs to be fixed to keep New Yorkers safe.
“The tragic loss of life in a fire, especially the loss of young children, reminds us why we must ensure that our 911 emergency system performs at its highest capacity,” he said. “The mayor is committed to the long-term structural reforms necessary to provide the people of New York with a 911 system that will continue to keep them safe. In the meantime, this administration is leaving no stone unturned in reviewing the current 911 call-taking system so that police, fire and EMS responders can be dispatched to an emergency quickly and efficiently.”
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