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Double fatal fire in Waukesha: 911 dispatcher error blamed


Investigators have determined that a 911 dispatcher error resulted in the deaths of a husband and wife in Waukesha. Kevin and Kim McQuade died last month after a fire broke out in their building on Lambeth Road near Oakdale Drive. Officials first investigated a software malfunction for delaying firefighter response. They said the delay was due to human error at the City of Waukesha Communications Center. Investigators released their findings Friday in a 284-page report. Read the full report Investigators showed an initial 911 call was made at 1:25:06 a.m. on March 8. Police were the first to respond. The first fire truck arrived on the scene 11 minutes later. that call. Officials said their response time target was six minutes. The report showed a minute-by-minute review of what happened while the building was on fire. “A technical failure of the Computer Aided Dispatch (CAD) software has occurred causing the automatic activation of the fire department’s alert system to fail. This failure has resulted in a response delay of over 5 minutes,” the report said. “While 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 delay in response.” Investigators said they reviewed technical aspects, personnel performance and policies and procedures. “While the review concluded that a technical issue was what precipitated the failure to notify the Waukesha Fire Department of the active structure fire, this review concluded that multiple protocols were improperly executed. or omitted entirely, but one stands out as the most notable, the 911/Fire dispatcher did not manually activate the station alert within one minute of the fire call entering the system CAD (Computer Aided Dispatch),” the report said. “Ensuring that fire personnel have acknowledged the call and responded is the primary core function for this dispatch station.” Officials concluded that there were no errors in the alert software. “The error was from the ProPhoenix CAD software,” the report said. “In addition to the technical aspects, there were protocol lapses that exacerbated the delay in dispatching fire personnel. Liability will be addressed based on training and reasonable expectations of known information.” Ensuring that fire department personnel acknowledge the call and respond is the primary core function for this dispatch position, investigators note. Three dispatchers were on duty the night of the fire. code in a police dispatch field rather than a fire dispatch field, investigators determined. “According to ProPhoenix, this was the reason the station alert was not working properly, but it was unknown that this link would generate four separate service calls and fail to send an alert packet to stati during the alert,” the report said. The dispatcher never received confirmation from the fire department that he had been received and did not activate the manual alert until five minutes later. It should have been done within a minute of the failure, according to the report. The dispatcher also manually activated each of the five fire stations individually rather than all at once. “Seconds are precious in an emergency,” the report said. The dispatcher also didn’t immediately upgrade the fire on demand. The technical failure was reported to the duty supervisor at 6:30 a.m. Two other residents had to jump from the second floor to escape the fire. Another woman in her twenties also suffered life-threatening injuries. system has been in place since 2007. The McQuades left behind a son and a daughter. Police said nothing in their review the case has reached criminal level so no charges will be filed. The fire was likely ac Incidental in nature. An internal investigation is underway. This could result in disciplinary action against the dispatcher. This individual has been placed on administrative leave while the investigation continues. Police said they would speak to the families of the victims about their findings.

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

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

Officials first investigated a software malfunction for delaying firefighter response.

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

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

Read the full report

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

The police were the first to react.

The first fire truck arrived on the scene 11 minutes after this call.

Officials said their response time target was six minutes.

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

“A technical failure of the Computer Aided Dispatch (CAD) software has occurred causing the automatic activation of the fire department’s alert system to fail. This failure has resulted in a response delay of over 5 minutes,” the report said. “While 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 late response.”

Investigators said they reviewed technical aspects, staff performance and policies and procedures.

“While the review concluded that a technical issue was what precipitated the Waukesha Fire Department’s failure to notify the active structure fire, this review concluded that multiple protocols were improperly performed or omitted entirely, but one stands out as the most notable, the 911/ Fire dispatcher did not manually activate the station alert within one minute of entering the fire call into the CAD (Computer Aided Dispatch) system,” the report said. “Ensuring that fire department personnel acknowledge and respond to the call is the primary core function for this dispatch position.”

Officials concluded that there were no errors in the alert software.

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

Ensuring that fire department personnel acknowledge and respond to the call is the primary core function for this dispatch 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 dispatch field rather than a fire dispatch field, investigators determined.

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

The dispatcher never received confirmation from the fire department that he had been received and did not activate the manual alert until five minutes later.

This should have been done within a minute of the failure, the report noted.

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

“Seconds are precious in an emergency,” the report said.

The dispatcher also did not immediately improve the fire on demand.

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

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

Another woman in her twenties also suffered life-threatening injuries.

Four other residents were in the building when the fire broke out and were not injured.

The computer system has been in place since 2007.

The McQuades left behind a son and a daughter.

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

The fire was probably accidental in nature.

An internal investigation is underway.

This could result in disciplinary action against the dispatcher.

This person has been placed on administrative leave while the investigation continues.

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


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