Audit Finds DC 911 Center Failed US Standards

Consulting firm Federal Engineering (FE) did the audit, assessing effectiveness against national standards by reviewing 2019 and 2020 call metrics and a sample of 911 recordings. FE evaluated OUC culture and training and reviewed the office’s technology and internal investigations. ODCA called for the review in September 2020 after complaints by advisory neighborhood commissioners (ANCs) and news stories, including a series of articles by Communications Daily, about failures sending first responders on time to the right locations. FE recommendations included adding supervisors, better enforcement of review and communications process, and increased training on location technologies.

“The comprehensive findings include inadequate supervision of the call-taking and dispatch operations, inconsistent or ineffective use of call script protocols, inconsistent use of location determining technology tools to determine locations, and insufficient management follow-up on after-action reviews,” wrote D.C. Auditor Kathleen Patterson in a cover letter to Mayor Muriel Bowser (D) and City Council Chairman Phil Mendelson (D): “The report notes that OUC is staffed with dedicated, well-intentioned professionals and that the issues identified by FE regarding call-taking and dispatch operations can be corrected to improve service to residents and responders.”

OUC took and is taking “positive measures to improve service delivery to our residents,” interim Director Cleo Subido said in a Tuesday statement. “We have made significant strides in call-taking metrics, maintaining a culture of accountability and excellence, supporting our staff’s mental health, and building collaborative relationships with partner agencies.” More work is required, Subido said. “Through significant investments in FY22 the OUC will continue recruitment efforts to ensure a full complement of call takers, enhance staff training to further improve the accuracy of address locations, launch a Supervisors Development Initiative aimed at developing our supervisors' skills to foster a supportive and fair working environment which is committed to operational excellence, and help our team at all levels to provide quality dispatch services to residents across all eight wards.” Some stakeholders have praised Subido for better communicating with them and the public and for trying to overhaul OUC.

D.C. Council Public Safety Chair Charles Allen (D) is glad FE “made extensive yet clear recommendations and concluded that these issues can be successfully addressed,” he said Tuesday. “Interim Director Subido has been hard at work at addressing these issues since her appointment, and I’m confident she will implement these recommendations to ensure that the District’s 911 system continues to meet the public’s safety needs.” Mendelson and Bowser didn’t comment. A union representing D.C. 911 staff declined to comment, while unions for police and fire-rescue personnel didn't comment, nor did the police or fire department.

Standards

In no month of 2019 or 2020 did OUC comply with a National Fire Protection Association (NFPA) standard requiring call takers to notify responders within 60 seconds, 90% of the time, for the highest priority emergencies, the audit found. FE looked at more than 2 million inbound emergency calls in those two years.

“The highest performance was November 2020 when OUC dispatched 23.7% of all FEMS Priority 1 calls for service within the 60-second period.” FE recommended automating dispatch notification to increase speed. FE didn’t directly compare Washington with other major cities, but on this metric D.C. “is somewhere in the 20th percentile,” said FE consultant Stephen Verbil in an ODCA virtual news conference Tuesday. “That is too low.”

OUC failed in several months of the two-year period to meet NFPA and National Emergency Number Association (NENA) standards requiring calls to be answered within 15 seconds 90% of the time and 20 seconds 95% of the time. OUC didn’t comply with the first metric in seven months of 2019 and two months of 2020; it failed the second in 11 months of 2019 and six months in 2020, said the report.

OUC dispatched an appropriate number of units in 97% of a 72-call sample, the report said. It performed location validation in 89% of the calls, gave appropriate prioritization in 85%, and selected the correct call purpose in 85%, it said. Units reached location within time limits in 97% of the calls, it said. FE also reviewed four high-profile calls selected by ODCA and found “direct correlations” between them and the common issues found in the 72 sample calls.

Call-taking problems included an inconsistent process, “improvising or adlibbing and a lack of use of protocols,” and failures to obtain callers’ full names or to verify, collect or enter apartment numbers into the system, it said. FE observed instances where call takers relayed “apartment numbers to responders [in]correctly or not at all,” it said.

Despite improvements in cellphone carriers’ location accuracy, FE’s call-taker observations “found no one using the map to plot the location of a caller but instead relying solely on questioning the caller for a location.” A review of internal investigations found “one dominant issue ... is the issue of accurately identifying the address (or location) of the call for service,” it said. “Caller location issues continue to be an ongoing problem for OUC call-taking staff.”

OUC Response

OUC made changes this year, Subido said in an Oct. 7 response to a draft report. Bowser’s “commitment to our success will help us build on these strides with significant investments in FY22,” she said. OUC is focused on improving address locations, Subido wrote. “The deployment of the RapidSOS location determining technology ... and continued engagement of call takers on the improved pinpointing of this technology has already paid dividends in call location accuracy.” OUC seeks to improve supervision including through more training. Call scripts are critical, though the agency seeks to avoid “excess prescriptive language,” she said.

ODCA will be following up on its recommendations and urges Allen’s committee to do the same through its oversight hearings, Patterson told reporters: “Our recommendations don’t just go on a shelf.” OUC’s problems “are not insurmountable,” the auditor said: They have been addressed elsewhere and some fixes are already in progress. Patterson noted some agencies push back hard on her office’s recommendations, but that wasn’t the case here.

OUC didn’t previously acknowledge systemic 911 issues. “As an ex-elected official and ex-politician, it’s always difficult to acknowledge problems with a service that is a life-or-death service,” Patterson said. “You don’t want to admit there can be anything wrong because it’s so scary and the stakes are so high.” The office should get performance improvement if it follows recommendations, said FE President Ron Bosco: “In the end, success builds trust.”

OUC’s response to ODCA's “extremely thorough” audit was good, said D.C. ANC 4B01 Commissioner Evan Yeats in an interview. The report’s section on internal investigations lined up with the opaque experience that Yeats had with former OUC leadership, he said. “You never felt that they thoroughly took seriously those complaints that came from constituents.” Subido is more transparent, responsive and consistent in information she shares, which shows the office might be heading in the right direction, said Yeats. That Subido is only interim director concerns Yeats, he said: It’s unclear if she has support needed from the mayor’s office. “The proof is in the pudding,” said Yeats. “It’s less about outreach” or “being community-facing than it is just about delivering results.”

ANC 4B06 Commissioner Tiffani Nichole Johnson would welcome OUC to visit and get to know her community better, she said. The agency needs a permanent director because interim means an “agency in flux,” she said. The commissioner wants deadlines set to ensure OUC implements recommendations, she said. The D.C. Council should quickly hold a special hearing on the audit’s findings, not wait for a general oversight meeting, she said: “There are lives that have been lost and lives at stake.”

Transparency

The 911 center under new leadership has generally been praised for increasing transparency. Subido was also more open than her predecessor about accuracy and other emergency dispatching challenges. She testified in March to the city council's Judiciary and Public Safety Committee.

OUC was initially fully responsive to Communications Daily Freedom of Information Act requests. A response last year allowed a complete review of some major errors that put lives at stake. After our report, which spurred Bowser and other city officials to say the problem would be addressed, the agency stopped responding to most of our FOIA requests. Lacking that information, it's impossible to determine what caused myriad dispatching errors. A staffer handling the matter said there's no update now.

In general, governments sometimes stop providing emergency communications records under state FOIA laws after some information they previously released is used by the news media or others to point up problems, said National Freedom of Information Coalition President David Cuillier. “The blowback reaction is that that information is shut down” by an agency, said Cuillier, an associate professor at the University of Arizona School of Journalism. “While I get the instinct to make that secret, to avoid being sensational and preying on people’s misery … ultimately, those records should still be available to see how the system is working. It is doing victims a disservice to hide that information.” Releasing such records can add transparency to 911 and other systems so problems are brought to light, leading to their being remedied, he said.

That a requester might use documents to unflatteringly portray an agency isn’t a good reason to subsequently decline to release records, said University of Florida College of Journalism and Communications professor Frank LoMonte. “Image maintenance” isn’t a good reason to keep documents private, added LoMonte, who directs the college’s Brechner Center for Freedom of Information. “Either prompt production of the records or some prompt explanation of why you can’t have prompt production of such records” is generally what’s required of government, he said. “Records of 911 communications are not exempt” from being publicized under D.C. law, unless it deals with an ongoing investigation, he noted. “There is not a categorical exclusion for 911 recordings under D.C. law” nor in most states, the FOIA expert said: “The presumption would be that these records are public.”

Editor's note: This is part of an ongoing series of articles about D.C. 911 dispatching issues. To read some recent top news stories on this, see here, here, here and here.