DC addresses problems with 911 call center response following outage
WASHINGTON - D.C’s Office of Unified Communications and government officials finally publicly addressed the cascade of problems with response on August 2, a day in which the computer dispatch system went down at the same time a 5-month-old baby stopped breathing.
The first call came in at 12:39:27 from what’s known as a NSI phone. Non-service-initiated phones are devices like burner phones that have no service plan but can still reach 911. Dispatch cannot call these phones back because there is no number. The caller was on hold, in the queue, for :54 seconds while an automated "please do not hang up" message played. At 12:40:21 the call was disconnected. The computer-aided dispatch (CAD) system went down at 12:40.
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OUC’s Director Heather McGuffin in a press briefing acknowledged that 54 seconds is too long to wait, attributing unacceptable wait times to staffing shortages.
She also said the CAD outage did not affect the separate telephone system.
City Administrator Kevin Donohue said the Computer Automated Dispatch outage on August 2 was caused by an IT contractor who mistakenly pushed a change to all devices rather than the few test devices that were intended.
The Office of Unified Communications immediately switched to manual mode. That requires a call taker to write down all the information on a quadruplicate form, then hand it off to a runner to distribute it to police, fire and EMS operations teams for dispatch.
Nine minutes passed until the baby’s parents called back. the father called in on a 240 area-code phone at 12:49:42. He connected to a call taker at 12:51:00, immediately gave his address and said "I’m doing CPR on my son, but he’s not coming back". The call taker gave instructions, and the caller advised that someone was giving CPR to the baby.
A call from the mother, using the same NSI phone, came in at 12:49:54. At 12:51:27 she told a call taker the baby was not breathing, that they were downstairs and there was someone who was in the building that was doing CPR.
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Transcripts provided by government officials say "the call is very muffled, call taker is attempting to say that help is on the way and there is help on the way. They were advised to keep doing CPR. Call taker advised caller the police would probably get there first, and that she needed to be outside to meet them and reassured her that she would stay on the line."
At 12:53:43 Engine 28, Medic 31 and EMS 5 were dispatched.
At the time, with the CAD system down, dispatch was not aware that transport unit Medic 31 was on another call.
An MPD Officer arrived at the address in the 3000 Block of Connecticut Ave NW at 12:53:55.
National Zoo police were also on scene.
Ambulance 28 arrived at 12:58:02 and took over the CPR in progress. An automatic external defibrillator was deployed and took recordings every 2 minutes. DC FEMS Medical Director Dr. Vitberg said the child had no cardiac activity and continued to be classified as "cardiac arrest".
At 13:05:20, Ambulance 28 learned that transport Medic 31 was still on another call. Other units and Medic 31 were routed to Ambulance 28, the child was transported with CPR in progress at 13:14:16.
A city audit found 18 disruptions or outages to the OUC in 2024. Some impacted only a few devices, but according to City Administrator Donahue, 8 had a broad impact.
Donahue confirmed that these outages are happening more frequently - 6 since May 2024. His analysis found there were no one or two causes. Instead, the city has identified 22 points of weakness, most having to do with outdated hardware. Donahue said the city is moving up the timeline to replace some of that hardware, including databases, servers, and network connections. In addition, they will make sure that the CAD system is on its own server.
Finally, new procedures are being put in place to keep better track of crew availability during manual dispatch mode.
Director McGuffin reported that the $800 monthly bonus program has been "wildly successful" in encouraging employees to not have unscheduled call-outs. 22 new employees are scheduled to start at the end of August, and the agency has received 420 new applications since the publicity about the performance bonus.