A Comm Center In Crisis
by Gary Allen
It's the most-used emergency number on the telephone and has become synonymous with help. But when a 20 year-old college student dialed 9-1-1 in San Francisco in 1990, he didn't receive the help he expected.
Instead, the man died, the dispatcher was fired, two families were devastated, and the San Francisco police department's communications bureau received a complete shake-up.
The incident highlights the influence dispatchers have on people's lives, and how that influence extends beyond the relatively few people who call for service. It also shows how newspaper editorials, TV stories, press conferences and community activists can create a tornado of criticism that can destroy a communications center and demoralize its personnel.
It all started in the seventh inning of a San Francisco Giants baseball game on September 29, 1990 when Scott Quackenbush and a friend decided to leave the game early. They drove just a block from the stadium in Quackenbush's prized 1967 Mustang when its engine stalled.
The friend urged Quackenbush to walk back to the stadium. But he insisted on staying with the car and eventually had it towed to a Union 76 station that had closed 90 minutes earlier.
A group of men in cars was drinking in the service station parking lot. Across the street, more men hung out at Judnich's, a local bar frequented mostly by men from the South Sea Islands of Tonga and Samoa.
As later reconstructed by homicide detectives, one of the drinkers approached Quackenbush's car, which was parked and covered in the rear of the lot with its alarm set. The alarm went off and Quackenbush yelled at the man to get away from his car.
The man protested that he was not bothering the car. Quackenbush ran for a nearby phone booth and at 1:42 a.m. dialed 9-1-1. San Francisco Police dispatcher Diane Fisher, 41, answered the call and questioned Quackenbush, who told her someone was trying to break into his car. On the logging recorder tape you can hear the sounds of arguing and then the phone being dropped.
Fisher typed the information into the police department's CAD system and classified it as burglary incident, with a "B" priority. Fisher did not telephone back to the phone booth and Quackenbush never dialed 9-1-1 again.
At 3:16 a.m. the incident was dispatched to a patrol car, which arrived within six minutes to find Quackenbush gone and no trouble in sight. They reported "UTL" and pushed on to the next call. It had taken one hour and forty-two minutes to respond.
Later that night Quackenbush's mother became worried when Scott didn't show up--he was very reliable. She called Scott's father Bill, an attorney who has lived near San Diego since their divorce. Bill Quackenbush called Scott's dormitory in Fresno and discovered he never returned. On Tuesday he hopped a flight to San Francisco to look for his son.
Bill Quackenbush and his current wife hooked up with San Francisco Officer Mike Pawsey and convinced him that something serious had happened to their son. The trio located the towing company Scott used and, at about 2:00 p.m. on Tuesday, tracked down where the car had been taken.
As they searched the service station lot, Officer Pawsey found Scott's Mustang, and then he found Scott, face down at the rear of the station, dead.
Police said Scott's Mustang had not been burglarized. His backpack, car keys and wallet were found at the scene. It didn't appear like a robbery or theft. It had been four days since Scott Quackenbush dialed 9-1-1 for help.
The Immediate Aftermat
Up to now, not much was mentioned about the communications center, the dispatcher or the way the call was handled. The discovery of Scott's body changed all this.
Bill Quackenbush went public with the story the very next day, charging that the police department delayed a response to his son's 9-1-1 call.
That same day, Police Chief Frank Jordan transferred dispatcher Fisher, a 10-year veteran, to duties that didn't involve public contact. Jordan said Fisher made a "judgment call" when she assigned the call as a priority "B" instead of the more-urgent "A."
The department was expediting its internal investigation into why the call received a low priority, Jordan said, but overall he felt, "The communications dispatchers are doing an excellent job."
Dr. Boyd Stephens, the city's coroner, reported that Quackenbush had died choking on his own vomit. His injuries included scrapes and bruises on the head, face, chest, abdomen and hands, and hemorrhaging in his neck. A shoe print marked one side of Scott Quackenbush's face.
The coroner's report said that Quackenbush might have died immediately, 10 minutes later or an hour later. There was no way to tell.
But when combined with another statistic--the 6-1/2 minute average response time for an A-priority incident--it raised a frightening question: Would Scott Quackenbush have survived if Fisher had classified the call as Priority "A"? Again, there was no way to tell.
Within days the public outcry over the incident began. The San Francisco Chronicle editorialized that, "The 9-1-1 number is the citizen's lifeline to authority--and help. This lifeline must be reliable.
"We all know that mistakes can be made under pressure. But a system like the 9-1-1 line should be geared to allow an absolute minimum of failure. When such a fundamental protective tool does not work, then public confidence collapses with it," the editorial concluded.
People began dialing 9-1-1 just to tell the dispatchers what a crummy job they were doing. To encourage a quick resolution to the case, Mayor Art Agnos approved a police department request for a $10,000 reward for information leading to the killer.
The Capture and Trial
Within 10 days, police had two suspects in custody. A stake-out nabbed two men on unconnected charges, and they pointed the finger at two cousins, Siosiua Livai and Totoa Pohahau, both 20 years old. They lived within a mile of the service station, were employed, had families and had never been arrested.
When arrested at work, Livai admitted his involvement. He and Pohahau had been drinking in the service station lot with others since about 9:00 p.m. He said around 1:00 a.m. Pohahau went to the rear of the lot to relieve himself and stumbled against Scott's Mustang, setting off the alarm.
Livai said he watched from a nearby car as Quackenbush and Pohahau traded shouts. Livai heard Quackenbush threaten to call the police. The yelling continued as Quackenbush dialed 9-1-1.
Livai described the terrible beating that Quackenbush absorbed and said he tried to pull his cousin off. He claimed the pair didn't know Quackenbush was dead until they later heard news accounts. Amid the publicity surrounding the case, both were held on $500,000 bail.
Homicide inspectors looked for a motive, but the most common ones quickly evaporated. It boiled down to a combination of ethnic pride and an alcohol-induced rage. But even with that explanation, none of it made sense to the community or the families involved.
At the three-week trial that ended on September 19, 1991 Livai was convicted of involuntary manslaughter and received a four year sentence. The jury deadlocked on the charges against Pohahau two days later.
Of that jury, seven jurors voted for second-degree murder, two for manslaughter and one juror--in a fit of pique--blamed police dispatcher Diane Fisher. The prosecution planned a retrial, but Pohahau pled guilty in January, one day before the trail was to begin. He was sentenced to six years in prison.
Not content with the criminal verdict, the Quackenbushes and Scott's mother filed a $2.5 million lawsuit suit against the city, the police department, Diane Fisher, the American and California State automobile associations and others liable for actions they feel led to the death of their son.
"The responding dispatcher failed to notify police of the urgency of the call and no response was made until 1 hour and 40 minutes later," the lawsuit said. "As a direct and proximate result of the city and county's failure to adequately provide emergency services, (Quackenbush) died from the mortal wounds received during the aforementioned attack."
The Comm Center
The San Francisco Hall of Justice is a massive, gray building off to the side of downtown. It looks very bureaucratic and strong enough to withstand the tornado of criticism that whirled up after Quackenbush's death.
Up in the fourth floor Communications Bureau, dispatchers handle 1.2 million phone calls a year, half of them on 9-1-1. They work 8-hour shifts, with six different shift configurations covering a 24-hour day.
The comm center is authorized to have 125 dispatchers, but only 105 positions are filled. Of those, only 86 positions are available for work because of sick leave and vacation. Pay starts at $32,000 and tops at $42,500 for a supervisor.
By any measure, the comm center itself is an eyesore. One newspaper story described it as an, "untidy room, with its banks of computer screens and telephones." A city report said, "The physical plant is inadequate and is unkept in some areas."
Calls are handled by a computer-aided dispatch (CAD) system. When an incident is taken, calls are classified by the dispatcher as either A, B or C priority.
"A" priority designates calls where there is danger of death or serious bodily harm, or a major crime in progress. "B" priorities are less critical situations but have a potential for physical harm or major damage to property. Both types of calls require an officer to respond. Priority "C" calls are where there is no danger to life or property, the suspect has left and the crime scene is protected.
On the night that Scott Quackenbush called, 10 dispatchers were on-duty. Diane Fisher later said she had a finger in one ear to block out the background noise of the center.
On the logging tape, Quackenbush's 9-1-1 call begins routinely, with Fisher saying, "Hello, San Francisco police 9-1-1. May I help you?"
"Uh, yes, I need help. Someone's trying to break into my car," Quackenbush said.
"Into your car now?" asked Fisher. Uh, yes," Quackenbush said.
Fisher asked Quackenbush where he is and his response was garbled.
She repeats the question and Quackenbush answered, "I don't know."
"How do you know somebody is breaking into your car, then," she said.
At this point, Quackenbush apparently takes the phone from his mouth and talks to someone nearby. "Oh, s--t, man, what the hell?" he said. "What the hell? That's my car, man. That's my car!"
This was followed by the sound of the receiver being dropped. After about 40 seconds, Quackenbush yelled, "Hey! What the f---," with a pained expression. His voice faded out and then, in the background, there is the sound of voices and screeching tires. After about 2 minutes, the phone is put back on the receiver and the connection ends.
The city's Board of Supervisors held a public hearing into comm center conditions on October 30, 1990, partly to find answers, partly to let the dispatchers blow off steam, but more to pacify the growing public outcry over the way the call was handled.
Three dispatchers reeled off a list of comm center deficiences, including insufficient staff, noisy conditions, poor equipment, bad morale and abuse of the 9-1-1 system. Citizens came up with their own list of problems, including dispatcher rudeness, busy signals on emergency lines, and long response times.
Dispatch supervisor Pam Katz told the panel there are usually about seven people answering phones at one time. "We need 20 additional bodies" to cover the various shifts, she said.
"Of all the calls we take on 9-1-1, I would say only 85 percent are real emergencies," dispatcher Laura Kracke testified. "In the course of an hour I must be psychiatrist, lawyer, doctor, operator, interpreter, marriage counselor and sounding board."'
Since the Quackenbush case was still active, the supervisors agreed not to ask specific questions about the incident. So next, they heard testimony from a long line citizens who read them the riot act about dialing 9-1-1.
Betty Mangual, who lives in the Alexander Hotel in the Tenderloin, charged that "9-1-1 treats you differently when they get the address."
Mangual said she called 9-1-1 and said, "I have epileptic seizures. I am about to be unconscious. This is my address. Can you get an ambulance?
"The dispatcher said, `What are you on? You just want to get attention,' and hung up," Mangual recalled. A neighbor found her unconscious and caller her daughter, who took her to the hospital.
Even city Supervisor Angela Alioto said she called 9-1-1 to report a suspected prowler in her house and got a taped message saying all operators were busy, please wait. When she hung up and called again, she got the same recording.
The Publicity Continues
By November 1st, the avalanche of sources, internal memos and tipsters was appearing regularly in the local newspapers. Apparently there had been some warning that the comm center was headed for a disaster.
In an August, 1990 memo obtained by The Chronicle, dispatchers complained that the 9-1-1 telephone system was "overwhelmed" with emergency calls creating a "critical situation."
"This outrageous pace cannot continue for too much longer without serious repercussions to follow," said one memos signed by 40 dispatchers.
In another memo dated September 8th, a dispatcher described the volume of calls "like trying to win the Indianapolis 500 in a stock Chevette."
The disclosures didn't stop there. The leaks also pointed a finger at Diane Fisher. By October 23rd, the public knew she was no ordinary dispatcher. A San Francisco Chronicle story revealed that she had "numerous" prior complaints, including one the previous March during a burglar call.
In that incident, a caller dialed 9-1-1 at 1 a.m. to report someone breaking into her house. Fisher handled the call, told the caller it was "no big deal" and to call her local police precinct. The called the precinct house and the police there kept her on the phone until a patrol car arrived and caught the intruder.
After the citizen complained, she received a written apology from Police Lieutenant Anthony Ribera, head of the Management Control Division, saying, "The action of this member does not conform to departmental policy and the appropriate disciplinary action has been implemented."
At the same time, KRON-TV reported that Fisher had been suspended three times for improper conduct, for a total of five days.
On March 22, 1991 Fisher appeared before the Civil Service board disciplinary hearing. Attorneys for both sides presented their cases to fire or retain Diane Fisher.
Attorney Jerry Aikens, representing the Police Department, presented a case to have Fisher fired. He cited five suspensions, five counseling sessions and two letters of reprimand during her 10-year career.
Fisher's attorney, W. Daniel Boone, pointed out that his client has also received at least two letters of commendation, and a couple of letters from citizens who appreciated her efforts to help them.
Dispatch Supervisor Toni Hardley testified that Fisher had attempted to improve her abrupt telephone manner and that she handled emergencies well.
Hardley said that it was not absolutely clear from Quackenbush's call that his life was in danger, and that Fisher's decision was not necessarily inappropriate under the circumstances.
But in early May, 1991, the board fired Fisher. Hearing officer William E. Riker ruled that Fisher violated departmental rules and procedures while answering the emergency call. Police Chief Willis Casey agreed with the decision.
Fisher did not comment on the decision, but attorney Boone said she was disappointed with the hearing officer's decision.
"I think the hearing officer was mistaken," Boone said. "He did not accept her explanation of what she heard and responded to. He disregarded the testimony of two supervisors--the two people who best understood what she was supposed to be doing--that she hadn't violated any rules."
Nevertheless, he said it is unlikely the firing will be appealed. "I don't think a court would be likely to overturn the decision," he said. "It probably wouldn't be worth the time and money."
At the Board of Supervisors request, the city's Budget Analyst produced a Performance Audit Report. Released on February 16, 1991, it contained 51 recommendations that painted a picture of a communications center-and police department-in trouble.
The audit showed that sworn officers ranked the Comm Bureau just above criminals, an unstable management structure hinders policy and technical developments, and many of the basic policies and procedures of a communications center were completely lacking.
The first recommendation pretty well summed up the Comm Bureau's problems: develop a mission statement, then goals and objectives for employees. Somehow, this vital step had never been undertaken.
The audit recommended development of a policy that rudeness, disrespect and/or deliberate subversion of a dispatcher or dispatch operations would not be tolerated.
"The reputation of Communications with SFPD management and field officers was not very high," the audit said. "Upper Police Department management was not very supportive," as well.
"Not only is there an historical bias against the unit," the audit reported, "but sworn officers and supervisors many times exhibit a negative bias toward civilian workers."
The nuts-and-bolts recommendations were also in the report: fund a civilian comm center manager, develop a detailed job description for dispatcher positions, closely monitor the use of sick leave and other absences, transfer five sworn officer positions in communications to other units, and track the use of language translation services.
"The morale and self esteem of the Communications Section personnel is the signal (sic) most reason for the staffing problems caused by sick day and other leave absences," according to the audit.
According to the report, during 1990 the average dispatcher was absent 31 days. Calculated another way, time off represented 13.4 vacant dispatcher positions.
The audit said that, because captains and lieutenants rotated in and out of the Comm Bureau, policies and procedures were changed frequently. This resulted in "operational disruption and stress problems for employees."
"Past management has not exhibited the technical knowledge nor the long term commitment" to make strategic decisions, said the audit. "Poorly formulated past decisions continue to cause severe problems."
The managment rotations also left the comm center without "a forceful spokesperson for the Center who can organizationally `fight' for needs or input on decisions," said the audit.
The audit found that on-going training of existing dispatche