Human Error Cited for Pa. Dispatch Snafu to Fatal Fire
Source The Citizens' Voice, Wilkes-Barre, Pa.
July 23--An internal review of Luzerne County 911's handling of a fatal Mocanaqua fire in which the closest fire department was not immediately dispatched has revealed human error was the sole cause, the county solicitor's office said Tuesday.
But a rebuttal report issued by the employee union Tuesday night blames a number of factors for the mistake, residents' lacking geographic knowledge, inadequate procedures and that the quality of dispatchers is at an "all-time low" because of employees are rushed through training due to short staffing.
A prepared statement issued by the solicitor's office says the phone and computer-aided dispatch system was in "proper working order" and the center's policies and procedures "were not a factor" the error. As a result of the fire, "personnel disciplinary adjustments" took place, the statement said.
"Since this incident took place, Luzerne County 911 has refocused the attention of 911 supervisors and staff on training policies and procedures intended to prevent incidents such as this," the statement said.
"Further, Luzerne County 911 will continue working with municipalities to resolve street name and address concerns. Finally, Luzerne County will continue educating the public regarding the importance of clearly stating location when reporting incidents via cell phone."
County officials fired 911 telecommunicator Debra Pac on June 3 in the wake of the blaze, which killed 52-year-old Michelle Dzoch. Another call center employee who has not been publicly identified was suspended without pay but later reinstated. In a report issued to Luzerne County Council on Tuesday night, Robert B. Bomboy, union steward of American Federation of State, County and Municipal Employees Local 1398, says many factors other than human error played a role in the dispatching mistake.
"No less than eight 911 employees had a role in the handling of this call," Bomboy wrote. "Yet the entire blame has been placed on two telecommunicators only."
The report notes that the "vast majority of residents of Luzerne County simply do not know where they live" -- they know their mailing addresses, but not the specific municipality in which they reside.
At the time of the fire, call-takers were also grappling with a shooting in Wilkes-Barre as well as other calls, according to the report.
The response says the telecommunicator who got the initial call dispatched the correct departments for the address provided. During a disciplinary hearing, county officials questioned why a policy of "if there's a doubt, send both out" was not followed. But the report says it is not clear at what point the communicators realized two locations were in play. The report claims the two call-takers disciplined had "excellent work records" and that they followed the procedures established by the county -- it was a lack of adequate procedures and "a history of non compliance to them" that played a role.
Since 2008, the number of dispatchers has dwindled from 65 to 58, including a "mass exodus of dispatchers" last year. As a result, many have been rushed through training and have not been fully trained, the response alleges.
"The events of that day are a tragedy. The response since then is also," Bomboy wrote. "911 dispatchers are human, humans make mistakes. It's clear there was no gross negligence."
When the fire was reported at 10:47 a.m. May 15, dispatchers first sent Sugarloaf Fire and Rescue, Hazle Township Fire and Rescue and Valley Regional Fire and Rescue to 76 Main St. in Conyngham Borough, according to dispatch records obtained by The Citizens' Voice. The closest of those departments is more than 15 miles from the location of the fire at 76 Main St., Mocanaqua, Conyngham Township.
The Mocanaqua Fire Company was dispatched at 10:52 a.m., and records show it was an additional six minutes before crews were en route to the fire, which was one-tenth of a mile away from the department.
County officials have said Pac relayed an incorrect address to the dispatcher despite safeguards designed to identify address errors in a county where many communities have similar names and the same street names.
The fire began with Dzoch's two grandchildren playing with a lighter in a bedroom. Firefighters found Dzoch's body in a second-floor bathroom after the fire was snuffed out. The coroner's office ruled her death accidental, saying she died of carbon monoxide poisoning. Whether the response delay was a factor in her death was undetermined.
570-821-2058, @cvjimhalpin
Copyright 2014 - The Citizens' Voice, Wilkes-Barre, Pa.
