Grand jury cites human error for 'unfortunate incidents'
by Colton Campbell and Winston Jones/Times-Georgian
Oct 04, 2012 | 4808 views | 5 5 comments | 25 25 recommendations | email to a friend | print
A special grand jury impaneled to investigate Carroll County’s E-911 system found that the computer-assisted dispatch was not to blame for “recent unfortunate incidents,” but that those incidents were “most likely caused by human error.”

“We, the grand jurors, find that the current Computer Assisted Dispatch (CAD) system to be an effective system, which does not need to be changed at this time,” the grand jury’s findings read.

The presentment made shortly after 9 a.m. Thursday also includes three recommendations to the Carroll County Board of Commissioners, none of which include retooling or replacing the system.

Included in the recommendations, however, is the suggestion of better communication between and among Carroll County E-911, law enforcement, emergency responders and county and municipal governments.

District 3 Commissioner Ashley Hendrix requested the grand jury look into the 911 system in August.

“I’m disappointed in their findings, but I have no regrets,” Hendrix said. “Because I stood up for what I believed in.”

Hendrix said that while the outcome of the probe was not the one she desired, she does not regret making the request. She also said she appreciated the investigation that she requested being carried out.

Commission Chairman Bill Chappell said he is not surprised the report was so “positive.”

“I am out at the 911 call center often, and I am pleased with its management,” Chappell said. “So I am pleased with this result.”

Chappell praised E-911 Director Trisha Orr, saying it’s a “tough department to be in charge of.”

Hendrix requested the grand jury because of June incident in which a Temple man died after emergency responders were sent to the wrong address.

Fred Langley, 73, of Temple fell in his driveway June 28 and died from diabetic shock. His wife, Reba, called 911 at 2:30 p.m. that day, telling emergency dispatchers to send responders to their house on Kathy Lane in Temple. Instead, responders went to Kathy Lane in Carrollton, about nine miles away, before realizing the mistake.

Chappell had called the mixup “pure human error.” He said the dispatcher responsible was terminated, saying there is “no room for errors like this.”

But Hendrix maintained that she believes the system caused the problem instead of the dispatcher. She said she voted against the county purchase of the CAD system after investigating a similar system in Coweta County.

“They got rid of their system,” Hendrix told the Times-Georgian in July. “At the time I talked with them, Carroll County took more calls than Coweta. And Coweta got rid of the system because of errors and dropped calls.”

Chappell disagreed with Hendrix, saying she didn’t have all the facts.

“Commissioner Hendrix spoke without knowledge or facts, and she has created severe problems for the county government,” Chappell said.

The grand jury met for three full days last week, Tuesday through Thursday. The jurors came back Thursday morning to vote on the drafted presentment, which was done unanimously in favor.

The grand jurors inspected the Carroll County E-911 site last week and observed the dispatchers at work in the 911 center. Jurors also heard testimony both on site and later in the courthouse. Also examined were various documents and 911 recordings. The grand jury heard testimony from county commissioners, members of law enforcement and other government employees.

Also in the presentment was a recommendation that the county user board, made up of all agencies involved in the emergency response process — including police departments, sheriff’s office, fire stations, the E-911 center and EMS — be “more engaged in the operations of Carroll County E-911,” as set by the county’s service delivery strategy, an agreement between the county and municipalities for how certain services should be delivered.

Carroll County’s service delivery strategy, which is up for its 10-year renewal this year, requires the user board to meet once per month and give recommendations to commissioners.

Coweta Circuit District Attorney Peter Skandalakis said the user board is supposed to be used primarily as an advisory or “sounding” board.

“The user board has not met as regularly as they should,” Skandalakis said. “And the grand jury wants that resource to be utilized.”

The grand jury finding concerning the user board reads, “The proper use of this board would have avoided some of the problems arising from a lack of communication among E-911 service users and county officials.”

Carroll County Attorney Cynthia Daley, Orr and shift supervisor DJ Perkins said the dispatcher did not ask the right questions of Langley during the call.

In all dispatchers’ employee manuals, Orr said, there is a list of questions to ask of callers. Orr said it has always been a part of dispatchers’ training and standard operating procedures for the call center.

First, dispatchers are trained to ask for the address of where the emergency is.

Second, the dispatcher is supposed to ask for or verify a cross street, a road that is near to the emergency address. For instance, the cross street for Kathy Lane in Temple is Bar J Road. In Carrollton, it’s Ho Lynn Trail. This is where the error occurred, Orr said, as this verification was not obtained by the dispatcher.

Perkins, the shift supervisor on June 28, said the dispatcher should have asked immediately what road Kathy Lane is “off of.”

“She confirmed the address,” he said. “And then, automatically, the next question is, ‘What’s that run off of?’ If the system automatically gives you a cross street, then you still verify it.”

In the call 911 recording on June 28 provided to the Times-Georgian, Langley can be heard stating she needed an ambulance to 60 Kathy Lane in Temple, Ga.

The operator then sent responders to “60 Kathy Lane” off “Ho Lynn Trail,” two streets in Carrollton.

Once there, responders asked dispatch if the caller meant Kathy Circle, seeing that there was no 60 Kathy Lane in Carrollton.

“Stand by, let me check,” the operator said. “They advised a 60 Kathy Lane.”

Once realizing the mistake, the operator canceled the Carrollton responders and asked for Temple Fire Department.

“You can cancel, I apologize,” she said. “This one is going to be the one in Temple. (Engine) 42, will you be in route to 60 Kathy Lane.”

Temple responders told the operator they were already en route.

The Board of Commissioners approved the $150,000 purchase of the system in 2010.

The final paragraph of the findings reads, “After careful consideration of the available evidence, we find that the CAD system now being used was not responsible for recent unfortunate incidents of misdirected emergency responders and that those incidents were most likely caused by human error.”
Comments
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RhettMillsaps
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October 07, 2012
I would like to thank Bill Chappell for being right to stand up for Carroll county, and to Ashley Hendrix, who lost her reelection for good reason, shame should fall all over you for accusing the chairman of stuff you knew he didn't do, and your hate for him is so clear, that is why the voters rejected you, you care only for yourself and the report came to late to prove Chairman Chappell was right and you of course, have been wrong to elect to start with, you are only concerned about yourself and the power taken from you to represent the people, praise God. Your cousin may be the new chairman, but I give him a short period of time, hanging out with you, to totally fail at his sworn duty and guess what, he will end up with you in a few short months when he finds out he has to work for a living and he has no clue what he is doing. I pray he doesn't try what you did Ashley and that is to personally gain from the position, the laws would put him in jail while you got a free pass, you care about yourself and that is all you have shown. The jury is in on your attackes on teh chairman and as expected, you lost your try to tarnish his reputation, but your day will come if you continue to try this, a law suit against you would be nice since you have such a problem with your mouth. Maybe you can get over yourself, I understand that you will be serving your family in the new government, what, counting all the funds you can arrange for your family, you will be watched as will your cousin and we will see how long it will take to get an indictment against all those who profit from the tax money, watched you will be, recorded you will be and believe me, your going out there and causing all this trouble for the taxpayers will come back to haunt you and your family. this is just not right and you will see. your day is coming, you have cost the tax payers no telling how much, but it is coming....\

tym5352
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October 06, 2012
I would like to say "Thank You" to Commissioner Ashley Hendrix for requesting an investigation into the 911 CAD. I would like to know how the grand jury came to it's decision by only speaking with the 911 Director, County Attorney, County Chairman, and other county government employees and not speak to the very employees that work with the system day in and day out with it's ongoing problems. How long did the grand jury observe? Having the user board more involved with the 911 department is a good idea, but do you think Director Orr is going to acknowledge that there are problems with the CAD? And why is Chairman Chappell out at the 911 center often?
GaVoter
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October 05, 2012
Yep! Miss Ashley's hysterical premature grandstand showboating has proven what everybody knew from the beginning: The purchased 911 equipment functioned properly but this tragic incident was unfortunate tragic human error and the offending 911 worker was been rightly terminated!

Mr. Chappell had this matter in full and calm control but if Bill says it's "up" then Ashley Hendrix has to run to the media and scream it is "down." Whenever Mr. Chappell has thoughfully researched any matter, Miss Ashley Hendrix has gone running to the media to hysterically claim the opposite.

Well good riddance to Miss Hysteria! It's a sad shame that Mr. Chappell can't remain as Chairman another 4 years but Carroll County voters will rue their unfortunate decision to go another way when the county government gets screwed up for real.
coolhandluke520
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October 05, 2012
Hell yeah, they should ride Assley out of town on a rail!!
Bridgetgirl
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October 05, 2012
The Biatche's are mad now!!!! you can't go against the Grand Jury...What ya going to dish out now..