Double fatal Waukesha fire: 911 dispatcher error blamed

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Investigators have determined that 911 dispatcher error lead to the deaths of a husband and wife in Waukesha.Kevin and Kim McQuade died last month after the fire broke out at their apartment building on Lambeth Road near Oakdale Drive.Officials initially investigated a software malfunction for delaying the firefighters’ response.They said the delay was due to human error in the Waukesha City Communications Center.Investigators released their findings Friday in a 284-page report.Read the full reportThe investigators showed an initial 911 call was made at 1:25:06 a.m. on March 8.Police were first to respond.The first fire engine arrived on the scene 11 minutes after that call.Officials said their response time goal is six minutes.The report showed a minute-by-minute examination of what happened while the building was on fire. “A technical failure in the Computer Aided Dispatch (CAD) software occurred that caused the Fire Department alerting system to fail to automatically activate. This failure caused a response delay of over 5 minutes,” the report stated. “While the initial information revealed a possible technical issue with our Computer Aided Dispatch (CAD) software, the direction of this comprehensive review was to examine all possible issues that may have contributed to the delayed response.”Investigators said they examined technical aspects, personnel performance and policies and procedures.”While the review concluded a technical issue was what precipitated the failure to notify the Waukesha Fire Department of the active structure fire, this review concluded multiple protocols were either improperly performed or omitted entirely, but one stands out as the most notable, the 911/Fire dispatcher failed to manually activate station alerting within one minute of the fire call being entered in the CAD (Computer Aided Dispatch) system,” the report said. “Ensuring fire department personnel have acknowledged the call and are responding is the primary base function for this dispatching position.”Officials concluded there was no error in the alerting software.”The error stemmed from the ProPhoenix CAD software,” the report said. “In addition to the technical aspects, there were protocol failures that exacerbated the delay of dispatching fire personnel. Accountability will be addressed based on training and reasonable expectations of information known.”Ensuring fire department personnel have acknowledged the call and are responding is the primary base function for this dispatching position, investigators noted.Three dispatchers were on duty the night of the fire.They were not publicly identified but had a combined experience of 20 years.The dispatcher in question had five years of experience.That person entered the call code into a police dispatching field rather than a fire dispatching field, investigators determined.”According to ProPhoenix, this was the reason the station alerting did not working properly. It was a known issue with CAD that the link between police and fire was one way, but it was not known that this link would generate four separate calls for service and fail to send an alert packet to station alerting,” the report said.The dispatcher never got confirmation from firefighters that it was received and didn’t activate the manual alert until five minutes later.That should have been done within one minute of the failure, the report noted.The dispatcher also then manually activated each of the five fire stations individually rather than all at once.”Seconds are precious during an emergency,” the report stated.The dispatcher also did not immediately upgrade the fire when requested.The technical failure was reported to the supervisor on duty at 6:30 a.m.Two other residents had to jump from the second floor to escape the fire.Another woman in her 20s also suffered life-threatening injuries.Four other residents were in the building when the fire started and was uninjured.The computer system has been in place since 2007.The McQuades left behind a son and daughter.Police said nothing in their review of the case rose to a criminal level so no charges will be filed.The fire was likely accidental in nature.An internal investigation is ongoing.That could result in disciplinary action against the dispatcher.That person was placed on administrative leave while the investigation continues.Police said they would be speaking to the families of the victims about their findings.

Investigators have determined that 911 dispatcher error lead to the deaths of a husband and wife in Waukesha.

Kevin and Kim McQuade died last month after the fire broke out at their apartment building on Lambeth Road near Oakdale Drive.

Officials initially investigated a software malfunction for delaying the firefighters’ response.

They said the delay was due to human error in the Waukesha City Communications Center.

Investigators released their findings Friday in a 284-page report.

Read the full report

The investigators showed an initial 911 call was made at 1:25:06 a.m. on March 8.

Police were first to respond.

The first fire engine arrived on the scene 11 minutes after that call.

Officials said their response time goal is six minutes.

The report showed a minute-by-minute examination of what happened while the building was on fire.

“A technical failure in the Computer Aided Dispatch (CAD) software occurred that caused the Fire Department alerting system to fail to automatically activate. This failure caused a response delay of over 5 minutes,” the report stated. “While the initial information revealed a possible technical issue with our Computer Aided Dispatch (CAD) software, the direction of this comprehensive review was to examine all possible issues that may have contributed to the delayed response.”

Investigators said they examined technical aspects, personnel performance and policies and procedures.

“While the review concluded a technical issue was what precipitated the failure to notify the Waukesha Fire Department of the active structure fire, this review concluded multiple protocols were either improperly performed or omitted entirely, but one stands out as the most notable, the 911/Fire dispatcher failed to manually activate station alerting within one minute of the fire call being entered in the CAD (Computer Aided Dispatch) system,” the report said. “Ensuring fire department personnel have acknowledged the call and are responding is the primary base function for this dispatching position.”

Officials concluded there was no error in the alerting software.

“The error stemmed from the ProPhoenix CAD software,” the report said. “In addition to the technical aspects, there were protocol failures that exacerbated the delay of dispatching fire personnel. Accountability will be addressed based on training and reasonable expectations of information known.”

Ensuring fire department personnel have acknowledged the call and are responding is the primary base function for this dispatching position, investigators noted.

Three dispatchers were on duty the night of the fire.

They were not publicly identified but had a combined experience of 20 years.

The dispatcher in question had five years of experience.

That person entered the call code into a police dispatching field rather than a fire dispatching field, investigators determined.

“According to ProPhoenix, this was the reason the station alerting did not working properly. It was a known issue with CAD that the link between police and fire was one way, but it was not known that this link would generate four separate calls for service and fail to send an alert packet to station alerting,” the report said.

The dispatcher never got confirmation from firefighters that it was received and didn’t activate the manual alert until five minutes later.

That should have been done within one minute of the failure, the report noted.

The dispatcher also then manually activated each of the five fire stations individually rather than all at once.

“Seconds are precious during an emergency,” the report stated.

The dispatcher also did not immediately upgrade the fire when requested.

The technical failure was reported to the supervisor on duty at 6:30 a.m.

Two other residents had to jump from the second floor to escape the fire.

Another woman in her 20s also suffered life-threatening injuries.

Four other residents were in the building when the fire started and was uninjured.

The computer system has been in place since 2007.

The McQuades left behind a son and daughter.

Police said nothing in their review of the case rose to a criminal level so no charges will be filed.

The fire was likely accidental in nature.

An internal investigation is ongoing.

That could result in disciplinary action against the dispatcher.

That person was placed on administrative leave while the investigation continues.

Police said they would be speaking to the families of the victims about their findings.




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