Portland Tragedy Uncovers Strained Communications
An investigation into a fatal Christmas day house fire in Portland (Ore.) has uncovered a simmering dispute between firefighters and the city's consolidated police-fire communications center.
The report, written by city attorney Jeff Rogers and deputy CA David Woboril said several factors contributed to a 10-minute response, including dead-end streets, lack of maps and ambiguous communications between dispatchers and responding fire units. "No single mistake caused the delay," the report stated. Two women died in the fire, but the city report did not address if they would have survived if fire units had arrived promptly. Firefighters claim they could have saved the two women if they had arrived two minutes earlier. "Although there were several opportunities to prevent the delay through decisive action, these opportunities were not recognized nor acted on by the people involved,'` the report said.
The first caller said the fire was about a block east of Southeast 72nd Avenue and Tenino St. Fire units were dispatched immediately. Five other callers reported the fire and dispatchers said they passed that information along to responding units via radio and mobile data terminals (MDTs).
However, firefighters said they didn't hear the enroute location updates and didn't see the MDT messages. According to the report, dispatchers, "assumed the information had been received and did not demand a confirmation of receipt of the information."
Within minutes, Engine 11 arrived at Southeast 72nd Ave. and Tenino, and the officer pressed the "at scene" button on the unit's MDT. Dispatchers saw the status change and believed that Engine 11 had arrived at the actual fire scene.
When this occurred, dispatchers stopped relaying updates to the fire units, believing they had located the fire, arrived at the house, and were now transitioning to firefighting operations.
By procedure, once fire units arrive at the scene, dispatchers are not to initiate radio transmissions, but rather they are to monitor the channel and respond only to transmissions from a command officer. In addition, previous complaints by fire officers about having to acknowledge voice updates made the dispatchers reluctant to confirm information with responding units that night.
In this case, just before fire units arrived, a dispatcher asked a unit to confirm they knew the fire was on Southeast 74th Ave. The fire officer responded, "Let us get there and we'll give you an exact address." In fact, fire units were able to see the fire on an adjacent street, but responded up two dead-end streets and then had to make U-turns in order to reach it. "The firefighters could see the fire, were certain they were very close to finding an approach to the fire, believed they had to find an approach on their own and kept trying to locate the approach," the report said.
Beyond any misunderstandings that night, the report hit hardest at the troubled relationship between firefighters and dispatchers that began four years ago when fire dispatching was civilianized and consolidated with police. As currently staffed, dispatchers rotate among duties during a shift, taking telephone calls and handling police and fire radio.
In the past, fire officials have complained that dispatchers have mishandled fire calls and said dispatchers should not rotate among duties.
The report suggested five solutions to the problems that occurred that Christmas night, and to soothe the relations between firefighters and dispatchers.
The report recommended that dispatchers occasionally spend two-weeks handling only fire incidents, so they better understand the procedures and responsibilities. It also suggested firefighters spend time sitting in with dispatchers and that dispatchers ride-along with fire crews, to learn more about each other's jobs. Fire chief Robert Wall believes dispatchers should specialize in fire dispatching and not rotate among duties.
But city commissioners Earl Blumenauer feels the current rotation scheme could be changed to improve operations. He planned to meet with Wall to discuss changes. Other reaction to the report was muted. Gillian Butler, a dispatcher and comm center union shop steward, said, "It could be our call next time. That's always in the back of our minds." Randy Leonard, president of the Portland firefighters union, was conciliatory. "These dispatchers did the best job they could under difficult circumstances," he said.
Portland commissioner Charlie Hales, who oversees the Fire Bureau tried to reassure Portland's residents. "I don't think people should feel in any way that the system is incapable of serving them. But like any complicated system, the system is capable of getting better."
After the report was released, the Portland Oregonian editorialized that "firefighters and the 9-1-1 dispatchers who replaced them must work together to save lives and property."
The newspaper gave the city a D grade "at the very least and the Fire Bureau itself an F."
It stated that a failure of communication was "central" to the delay that occurred and that a false arrival report "misled" dispatchers. The newspaper called the fire bureau's procedures "officious" and said they "prevented those dispatchers from being able to help out once things began to go awry."
"Firefighters now say the `arrival' signal was given accidentally, but accident or not, the `arrival' signal should not discourage 9-1-1 dispatchers from passing on corrected directions to fire scenes," the editorial said. "This tragic pig-headedness in communications appears to be the fallout from a long-lost labor dispute in the bureau as opposed to being a useful firefighting tactic," said the newspaper.
The editorial noted that firefighters have complained since being replaced with civilian dispatchers and "have not been enthusiastic partners in the transition." It said the "undisguised frostiness of firefighters has discouraged dispatchers from speaking unless spoken to by fire officers."
The editorial hit hardest by saying, "That this could lead, even indirectly, to the deaths of two human beings is a disgrace that the Fire Bureau will not soon live down." It noted that Randy Leonard, president of the firefighters' union, expressed surprise that the relationship between his members and dispatchers remains unsettled. "We lost that battle," he was quoted in the editorial about civilianization. "Now I see our job is to help these dispatchers be the best they can be."
Of his statement, the Oregonian said, "Fine words, but empty ones, under the circumstances."
The newspaper concluded that all of the report's recommendations should be implemented, and suggested that management and the firefighters' union begin talking about implementing them. The editorial also suggested streamlining the information sent to MDTs so it's easier to read. But the biggest change, the newspaper said, should come in attitudes. "Lives, property and tax dollars are at stake."