Glitches plague Tucson's 911 system

New problems cited as possible factor in death of 10-year-old
2011-07-14T00:00:00Z 2011-07-14T11:21:19Z Glitches plague Tucson's 911 systemFernanda Echavarri and Rhonda Bodfield Arizona Daily Star Arizona Daily Star

Tucson's new 911 emergency call system has been plagued by technical malfunctions and dropped calls in its first six weeks of operation, and may have been a factor in the death of a 10-year-old girl.

Although the city official overseeing the system maintains he has no knowledge of any incident in which public health was compromised, a memo from City Attorney Mike Rankin advised council members not to enter into any discussions about the death of the girl, saying any written responses "in connection to this tragic event will only confuse matters and create more issues to deal with."

The problems include screens that are supposed to show the address of incoming calls not working, an elevated number of dropped calls and a reduced ability for supervisors or others to monitor calls for accuracy.

The city is nearing completion of a 60-day trial of the new system, which was put into service on May 25. But there is no practical way to go back to the old system because the wiring and equipment have been dismantled.

Ron Lewis, the city's general services director, said the problems are being worked on.

He said that while there was an "elevated risk" to public safety early in the transition, he believes that risk no longer exists.

But Councilman Steve Kozachik is critical of the city's handling of the implementation. "We've backed ourselves into a corner," he said. "We have left ourselves without options. As to the question about what options we have if we're not satisfied, the answer is, 'We don't know.' "

Kozachik said the city's insistence that it knows of no public harm since the switch is in "direct contradiction" to what he's been told from those working closely within the system. In a letter to City Manager Mike Letcher, Kozachik said it's his understanding the death involved a combination of factors, including operator error and problems with the new system.

Although 911 systems should be upgraded every five years, in 2007 the state had only enough money to update the system used by Tucson Police Department. That left rest of the city's 911 system - which serves the Northwest, Picture Rocks, Avra Valley, Three Points and Tucson Fire departments - outdated by at least five years, so the city couldn't get new parts or maintenance support.

The state pays for 911 systems statewide from a tax on cell and land-line phones. But the Legislature has seized $35 million from that fund over the past five years to balance its own budget, with another $2 million coming next fiscal year, said Alan Ecker, spokesman for the Arizona Department of Administration.

Because funding was limited, the decision was made to plug the city's new 911 system into the existing one used by Tucson police.

Six days after the changeover, a little girl was taken by her father to the Continental Reserve Urgent Care facility, 8333 N. Silverbell Road, unable to breathe. The facility is less than two blocks from a Northwest Fire District station.

But according to 911 tapes released by Northwest Fire Wednesday, when the call came in at 4:01 p.m., a distressed urgent-care nurse gave the dispatcher the wrong address by one digit, saying she was at 833 N. Silverbell Road by mistake, and reporting a 10-year-old girl was unconscious and in "respiratory arrest." The dispatcher repeated back the wrong address. At 4:02 p.m., he sent emergency crews from the Tucson Fire Department to 833 N. Silverbell Road, near downtown, instead of to the Marana clinic.

Six minutes later, an urgent-care worker called back, this time giving the correct address for the urgent-care center. But the dispatcher repeated back the original incorrect address to her, which she then confirmed - incorrectly, the tapes show.

At 4:10 p.m., the worker again called back, asking why assistance wasn't there. "They're still not here, and they're right across the street from us," she said. Workers at the medical center were unable to help the girl because they didn't have the necessary equipment to handle the emergency.

Once the address was corrected, emergency crews from Northwest Fire District were dispatched at 4:10 and arrived within two minutes, reports indicate.

The girl was taken to University Medical Center, where she was pronounced dead.

Under the old system, multiple dispatchers and supervisors were able to be on the line, providing a cross-check that could have alerted the correct emergency services sooner. Another listener might have recognized the name "Continental Reserve" as being on the northwest side or caught the correct address when the second call came in.

Although the city declined to address this specific case, Carla Reece, a 911 expert with Northwest Fire who previously worked for the city dispatch center, said based on city reports, the screen that normally shows the address where calls are coming from did not function in this case, which would have allowed another cross-check.

There also would have been another visual cue, since under the previous system, dispatchers could differentiate between city and county calls.

The dispatcher who handled the call was fired.

Lewis acknowledged that while the old system was outdated, it had fewer problems than the new system has had.

Holding his hands about a foot apart, Lewis said he had hundreds of complaints from staff members that had been given to the contractor, Qwest, about the new Vesta program.

Lewis acknowledged the address screen pops up less than half of the time under the new system.

He said it was "disturbing for everybody" when calls couldn't be transferred from the 911 operators to the correct dispatchers.

And while he said the system "often" dropped calls within the first week, he believes that is less of a problem of late, although he had no actual figures to support that assessment.

Before the rollout, Qwest provided a list of potential glitches with the implementation. Lewis said those all happened, but "there were additional problems experienced beyond what was anticipated." And, he said, they were also more extensive than the city had been told.

Although there were well-known problems during the Police Department's 2007 transition, Lewis said he had no idea if there were any lessons learned and applied to the new switch. He said no obvious problems were identified in dry testing of the system, although he could not provide details on what the testing showed before the system went live.

Dispatchers received roughly four hours of training before the transition. Reece said when the city went through a previous system switch, employees had four days of training.

The city has not done any statistical analysis to show how the new system is working or how it compares to the old one, because resources are short, Lewis said.

In a department that might see an employee fired about once a year on average, three employees have been fired within the last week. But he said the terminations had nothing to do with the new system, although he declined to provide details on the cases.

In a letter to Lewis, one public safety dispatcher said there were too many red flags since the switch.

"I am a public safety dispatcher that dreads the idea that if I have an emergency, my call will ring into our center, because the quality of service has degraded so much in just the last 30 days," she wrote.

Lewis said he believed the employee was "trying to make a strong point."

Kozachik has requested a public discussion of the problem at the council's August meeting.

Contact reporter Fernanda Echavarri at fechavarri@azstarnet.com or 573-4224. Contact reporter Rhonda Bodfield at rbodfield@azstarnet.com or at 573-4243.

Copyright 2014 Arizona Daily Star. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

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