Human Error Caused Deadly Delay, Not CAD

An in-depth investigation into a four-minute response delay to an auto-pedestrian accident that killed a 4 year-old New York City girl last June has concluded it was caused by human error, and was not the fault of the city’s 911 or computer-aided dispatch (CAD) systems. In an 43-report released today, the city’s Department of Investigation (DOI) concluded that dispatcher Edna Pringle simply failed to notice a pending medical incident on her computer screen for almost four minutes, then logged out and went on a 30-minute break. Her relief dispatcher logged in within 26 seconds, noticed the vehicle accident involving Ariel Russo and her mother, and took action within three seconds. A lieutenant supervising Pringle also did not see the incident, either on her screen or a larger screen at the front of the room. Russo was run down and pinned against a fence, and died at a hospital. Her mother was seriously injured but survived. The DOI said that Pringle had spoken on her personal cellular phone four times in the minutes before the incident—against policy—but that the calls did not affect the response time. The agency detailed how that the police, fire and CAD computer systems interact, requiring a “relay desk” dispatcher to view medical incidents reported by NYPD, and prepare them in the EMS computer for dispatch. The DOI also took a swipe at the fire department investigation, saying some witnesses were allowed to read other dispatcher’s statements before writing their own, putting accuracy into question. Some dispatchers said they were unfamiliar with various features of the CAD software, including how pending incident are displayed in reverse after being held for three minutes. Pringle was disciplined over her inattention, but the city hasn’t released details. Download (pdf) the full DOI report here.