Dave Statter: One year after deadly Kennedy Street fire, still lots of problems at DC’s 911 call center — and no effective oversight
The excuses were pitiful. Shameful even. A 911 center’s director and staff tried to convince everyone nothing was wrong with dispatchers taking four minutes to process a call for a house fire with people trapped. The director told one reporter that “there was no delay, no slow response.”
Questions continued. Tactics shifted. We were told time isn’t that important when trapped in a burning home: “We’ve shied away from rushing through calls, and we really look at the quality of a call.”
More absurd excuses followed: A police officer reporting a fire is an extremely rare thing. It takes longer to process emergency calls that are received by police radio than via a 911 line. The 911 center was also handling a call about chest pains at the same time.
Then there was the public testimony where the agency’s director failed to provide key information about a mistake 911 workers made while processing the call.
Outrageous justifications for complete failure. An attempt to defend the indefensible. But you know what? It worked.
That’s right. These nonsensical excuses from the director and staff at DC’s Office of Unified Communications (OUC) served their purpose. In the end, OUC was the only DC agency connected to the tragic fire at 708 Kennedy St. NW that escaped investigation and accountability. And now — in the year since that fire — many others have suffered due to DC 911’s failures.
A deadly morning at 708 Kennedy St. NW
It was 9:36:16 a.m. on Aug. 18, 2019, when the DC police officer called OUC on his radio to report a fire at 708 Kennedy St. NW. At the same time, the officer was desperately trying to get into the building to reach 9-year-old Yafet Solomon and 40-year-old Fitsum Kebede. A 911 center should dispatch firefighters and paramedics to a high-priority call like this within a little more than a minute. The first crew from the DC Fire and Emergency Medical Services Department wasn’t dispatched until 9:40:17. Four minutes and one second. A tragic operational failure.
Mayor Muriel Bowser demanded answers after the fire. She ordered an outside investigation into three separate DC agencies, each of which had a connection to 708 Kennedy St. NW. OUC wasn’t one of them.
The other agencies — the Department of Consumer and Regulatory Affairs, the Metropolitan Police Department, and DC Fire and EMS — were under scrutiny for what happened before the fire. 708 Kennedy St. was a fire trap. A police officer had discovered that five months earlier, but his various attempts to get the proper city agencies to deal with the dangerous conditions and prevent a tragedy failed.
The investigation and news coverage about the events on the day of the fire showed a series of moments where different decisions or actions might have saved two lives. There was candor and accountability about the mistakes that occurred before the fire. But why did it stop there? Why wasn’t there similar interest in examining and correcting the ways the city failed after the fire started?
The four-minute delay wasn’t completely ignored. There was some news coverage, and even a DC Council hearing in November where OUC’s director, Karima Holmes, was questioned. Her answers to council members — like her responses to reporters — defied logic and lacked candor.
Holmes made the case that the dispatchers needed more information before sending anyone from DC Fire and EMS. Holmes testified that knowing the address, that it was a fire and that people were trapped was just not enough information to dispatch DC Fire and EMS. Holmes said dispatchers were having trouble confirming exactly what was on fire.
It was clear that council members weren’t buying what Holmes was selling. DC Council Chairman Phil Mendelson tersely ordered her to send him and Judiciary and Public Safety Committee Chair Charles Allen the recording of the radio traffic with the police officer who called for help. They wanted to evaluate for themselves if DC Fire and EMS could have been dispatched within seconds and not minutes. That demand for the audio and the council hearing were pretty much the last official public actions and comments from DC officials about OUC’s handling of the Kennedy Street fire. Any thoughts of getting substantive answers and trying to prevent future OUC failures died that day.
What the DC Council missed
We still don’t know if Mendelson and Allen received that crucial recording. If they got it, we don’t know what it said. No recording. No transcript. No oversight. No accountability. No answers. The one recording that speaks directly to each of OUC’s awful excuses remains a mystery to the public.
Here’s what’s not a mystery: OUC’s own documents show Karima Holmes was not candid in her testimony. While Holmes made lots of excuses and explanations, she failed to mention an extremely relevant fact about the four-minute delay. OUC’s computer-aided dispatch chronology shows a 911 worker made an error that further delayed the call.
The chronology shows that a building fire was confirmed at 9:38:28, more than two long minutes after radio contact was initiated. But when Holmes went over the chronology of the call during her testimony, she failed to mention that 41 seconds after that confirmation — with still no dispatch of services — the call was wrongly coded as “structural damage” at 9:39:09. It wasn’t corrected for another 43 seconds, at 9:39:52. There was no mention of this at the hearing. It took until 9:40:17 — yet another 23 seconds later — to finally dispatch the call.
Think about that: OUC had every bit of information its director said was needed, and it still took almost two additional minutes to alert DC Fire and EMS about a fire where there “are kids inside.”
Kennedy Street is a repeat of L’Enfant Plaza
This isn’t the first time OUC escaped real oversight and accountability. On Jan. 12, 2015, OUC took at least five minutes to dispatch DC Fire and EMS to a fire in a tunnel near the L’Enfant Plaza Metro station. This was on top of Metro’s more than 15-minute delay in calling for help. OUC and Metro wasted time that Carol Glover didn’t have. She died gasping for breath on the floor of a Metrorail car. Scores of others suffered smoke inhalation.
The National Transportation Safety Board (NTSB) investigated the L’Enfant Plaza fire. NTSB’s findings included a recommendation that OUC get an independent audit of how it processes 911 calls. OUC has never met NTSB’s requirements, and the recommendation is still considered open. In January, Charles Allen, the DC Council member in charge of OUC oversight, told reporter Sloane Airey he had “no position” on OUC not following NTSB’s recommendations. That “no position” response came four months after two people died on Kennedy Street and two months after the council hearing.
OUC woes continue into 2020
As you can imagine, with no substantive oversight performed and two opportunities for outside investigations squandered, OUC has not improved. How bad is it? I’ve tried to answer that question with extensive monitoring of radio traffic since October. During that time, with the help of OpenMHz.com, I’ve documented about 200 incidents, but it’s clear to me that I’m just scratching the surface.
The radio transmissions I’ve captured show clear patterns. Wasting DC Fire and EMS resources is the most common issue. OUC does this by regularly sending duplicate dispatches to the same call. It’s almost an hourly occurrence. Recently, OUC dispatched four different assignments to the same patient near New York and Florida avenues in Northeast. The four locations were all within a thousand feet. OUC didn’t warn the responding units they were operating so close to each other. They also didn’t figure out these were likely the same call. Duplicate dispatches like this occur so often that it’s now routine for DC Fire and EMS units to scan the dispatch tablet in their rigs to determine on their own if someone else was already sent on the same run.
Thanks to the abundance of cellphones, duplicate calls are an issue at all 911 centers. That’s why dispatch software automatically alerts 911 workers to calls for the same address or in the same general area. It’s not clear why this feature isn’t preventing more of DC’s duplicates. In addition, call-takers and dispatchers who are well-trained on roads and geography can help prevent the problem. A long-standing criticism about OUC is that many 911 staff members don’t have a good working knowledge of the city.
My monitoring has pinpointed nine times since Feb. 25 where OUC apparently abandoned emergency radio channels. These channels have gone unanswered for as long as seven minutes. This radio silence occurred when an ambulance crew under attack called urgently for police; when an ambulance crew needed help for a patient in cardiac arrest (recording below); and when DC Fire and EMS was trying to determine from police if a shooting scene was safe to enter.
Another revelation: Once OUC dispatches a unit, it rarely cancels the call. My estimate is that close to 90% of the time it’s left up to DC Fire and EMS to figure out if a call should be canceled. The firefighters, paramedics and EMTs have to read through dispatch notes to discover that a patient has left the scene or that their crew is no longer needed. They do the job the dispatcher is failing to perform.
Recently there have been a couple of mind-boggling errors. On Aug. 2, during a triple drowning, the crew of a DC Fire and EMS boat clearly asked OUC to send additional help to the marina at Joint Base Anacostia-Bolling in Southwest. Instead, OUC dispatched the units to a marina five miles upriver. On Aug. 10 (recording below), OUC completely forgot which ambulance had called into two dispatchers to say they had been struck by a car being chased by police. Instead of sending help to Ambulance 19B in Anacostia, OUC dispatched the units to Ambulance 16 seven miles away in Brookland. It took 12 minutes and the intervention of a deputy fire chief to straighten out the mistake.
Generally, OUC’s public reaction to the incidents I’ve found is to say that radio traffic alone doesn’t provide a complete picture. On that, OUC is correct. The radio transmissions usually provide the what and not the why. But the only one who can tell the rest of the story about these incidents is OUC. Officials there have chosen not to participate. In fact, they long ago stopped even acknowledging my emails. I imagine that if any of my facts were wrong we would hear from OUC. That has not occurred.
Mayor Bowser has been asked at three different press conferences since October about OUC problems. The most recent was yesterday, when in response to reporter Tom Sherwood, she said, “I’m not going down that rabbit hole with Dave Statter.” While never providing specifics in her OUC responses, Bowser has steadfastly supported Karima Holmes. In April, Bowser called Holmes a “phenomenal leader” that DC is “lucky to have” run its 911 center.
Four cardiac arrest calls dispatched to the wrong location
On June 9, I posted recordings of two cardiac arrest calls that OUC dispatched to the wrong location. One involved a 59-year-old woman, and the other was a child, just born. During a DC Council budget hearing the same evening I posted my story, Allen asked Holmes about my reporting. Her reply (below) was about a pair of cardiac arrest calls she recalled that had been dispatched to the wrong location. Holmes said the misdirection of DC Fire and EMS was the fault of the call-taker in one of those incidents and of the person who called 911 in the other.
The problem is Holmes apparently wasn’t even talking about the two calls I shared. She told Allen that the calls she remembers were pre-COVID or early in the pandemic. The cases I wrote about had occurred months later on May 17 and June 5.
This means there have been at least four cardiac arrest calls sent to the wrong address this year. It’s astounding that more than two months after the June hearing, we have not heard one word from city officials about those four cases. No investigation. No outrage. Is anyone sensing a pattern?
Unchallenged bad practices become de facto policy
Whether it’s a delayed call to a woman taking her last breaths inside a smoke-filled subway train, or four people in cardiac arrest waiting for an ambulance sent to the wrong location, or a man and child trapped in a burning home while dispatchers dawdle, it’s clear no one cares enough to fix the problem. The deaths of these people, combined with the continuing pattern of chaos and dysfunction at the 911 center of the nation’s capital, somehow aren’t worthy of a real investigation or real oversight.
Here’s something you can count on. There will be more pain and suffering at the hands of the Office of Unified Communications. And when another death during a 911 failure actually makes news, expect more nonsensical answers from those in charge at OUC. By failing to properly investigate OUC’s handling of the Kennedy Street fire, DC’s leaders have officially accepted that promptness and accuracy are no longer key measurements at the 911 center. Remember, it’s the quality of the call that matters most. Good luck with that.
Dave Statter is a former television and radio reporter who, since 2007, has operated Statter911.com, which covers fire and EMS news in and from the national capital area.
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