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'Complicated' and 'Flawed' Dispatch System Resulted in Fire Deaths: DOI

By Katie Honan | October 21, 2014 3:55pm
 Pallbearers carried out the body of Jai'auni Tinglin at his funeral. Investigators found the response to the fire was delayed due to a flawed dispatch system. 
Pallbearers carried out the body of Jai'auni Tinglin at his funeral. Investigators found the response to the fire was delayed due to a flawed dispatch system. 
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DNAinfo/Katie Honan

FAR ROCKAWAY — The city's “unduly complicated and unacceptably flawed” ambulance dispatch system and human error produced delays of more than 20 minutes that led to the deaths of two half-siblings in a house fire in April, according to an investigation.

And the Department of Investigation, which conducted the probe, is calling for the immediate overhaul of the ambulance system in the wake of the deadly incident.

Jai'Launi and Aniya Tinglin, both 4, were killed in the April 19 fire, which also injured Jai'Launi's twin sister, a 55-year-old woman and a 63-year-old man.

It took 21 minutes after the first 911 calls were made for an ambulance to be dispatched to the home on Bay 30th Street near Bessemund Avenue, which investigators determined was the result of an “antiquated, unwieldy system,” according to the report released Tuesday.

The FDNY’s current procedure requires seven people to dispatch an ambulance to the scene of a fire after a 911 call, according to DOI’s investigation — a member of the NYPD, four members of the FDNY and two members of the city’s EMS.

On April 19, the system was “marred by errors,” the investigation found, from both the complex dispatch system and miscommunications.

This resulted in the “unacceptable” delay to the fire, investigators found. 

“DOI’s investigation exposed an antiquated, unwieldy system for dispatching ambulances to the scene of an active fire that substantially increases the opportunity for human error,” said Commissioner Mark G. Peters.

“We must start to overhaul this process immediately."

Peters added that the FDNY "has taken positive first steps by implementing preliminary remedies to streamline the process, but it must continue to pursue more advanced solutions.”

Fire Commissioner Daniel Nigro said the agency's "goal is to do the best job possible on every emergency call we handle." 

“We’ve implemented several procedural changes and are investing in technology to make certain that there’s no delay sending ambulances to fires," he said. 

On April 19, the first 911 call came in at around 11:51 p.m., and was first received by the NYPD, who then transferred it to the FDNY, according to investigators.

Firefighters were dispatched within a minute of the call, and arrived at approximately 11:56 p.m.

The FDNY commander at the scene confirmed that there were people trapped inside but EMS was not notified until seven minutes later because of human error and the multi-step process, the investigation found.

A witness described the chaotic scene to DNAinfo as FDNY members screamed over their radios for medics to get there.

"'EMS we can't do this alone. Where is EMS?'" Megan Maloney, 19,  said she overheard firefighters say while they performed CPR on the children in front of the home.

DOI also found a history of systemic problems within the dispatch system and disciplinary issues with those working on April 19.

The ambulance dispatch system is scheduled to undergo an overhaul along with the city’s 911 system — but it wont be ready until 2016.

In the interim, the DOI suggested streamlining the dispatch process and improving  the supervision of dispatchers, including planning meal and other breaks ahead of time so there's appropriate coverage.

On April 19, some dispatchers were not at their desks when the initial calls came in, the investigation found.

No criminality was discovered, but two dispatchers who were placed on a 30-day suspension last spring remain on administrative leave, the FDNY said. 

DOI also suggests the FDNY enhance communication between the fire and EMS dispatch systems as soon as possible.

The FDNY said the process will take six months, according to the DOI.