911 dispatch delay may have contributed to man's death
911 dispatch delay may have contributed to man's death (Part I)/ CNYCentral Matt Mulcahy
BALDWINSVILLE, N.Y. -- Larry Gillette died in a tragic apartment fire in Baldwinsville nearly three years ago.
Investigators ruled the fatal fire was caused by oily rags that spontaneously combusted.
CNYCentral is now learning Onondaga County launched a previously undisclosed investigation into his call for help that revealed a nearly 5-minute delay in the dispatch of the fire department may have been partly responsible for his death, according to documents obtained by CNYCentral.
NIGHT OF NOVEMBER 29, 2012
It was 2:02 a.m. on Nov. 29, 2012 when a panicked Gillette called 9-1-1 to report he was having difficulty breathing.
He was alone in his Baldwinsville apartment and desperate for help.
An Onondaga County dispatcher initially sent out Baldwinsville Rescue, but a quality assurance review of the call revealed that changed 1 minute and 26 seconds later when Gillette reported there was smoke in his Conifer Village apartment.
Only 12 seconds after that, Gillette reported he was trapped inside his apartment.
According to a Quality Assurance Review of the incident by Supervisor Of Dispatch Operations Michael Cramer, 5 minutes later, at 2:07 a.m., the call taker heard a loud noise and alarm over the phone.
In a Dec. 3, 2012 report by Public Safety Shift Supervisor Don Grevelding, the call taker stated Gillette told her something had exploded and was on fire.
A little over 30 seconds later, police arrive on scene and report heavy fire from the man's second floor apartment, according to the Quality Assurance Review. At the time of the fire, officials explained officers tried to reach him, but were unable to do so due to the severity of the flames and smoke. They then tried to enter through the rear upstairs window, but, again, they were unsuccessful.
A timeline reported by SODO Cramer shows it was then the fire dispatcher dispatched Baldwinsville Fire Department to the scene -- That was 4 minutes and 54 seconds after Gillette reported smoke inside his apartment, according to Cramer's review.
Firefighters were able to remove Gillette from his apartment and take him to St. Joseph's Hospital where he was pronounced dead.
The investigation into the cause of the fire revealed he had recently applied linseed oil on the stairs of his apartment and failed to properly dispose of the oily application rags, according to police.
Police say the oil and rags were placed in a closet where they spontaneously combusted and started the fire.
Larry Gillette grew up in Baldwinsville the oldest of three boys. He served in the military. He loved watching sports. His family says he was content living with his little dog.
"He was a good hearted person, he thought the world of me," remembers his mother Gail Gillette. "If I say there's something I want he'll always go out and get it for me. I just miss him."
Brothers Randy and Patrick Gillette remember the night Larry died.
Almost 3 years later, Randy and Patrick can still recall the night they learned their brother died. In an interview with CNYCentral earlier this month, Randy explained he heard the sirens during an overnight break at work. He says he did not know they were rushing to help his brother escape the fire. Patrick works nights on the railroad. He recalls the Baldwinsville Police Department coming to his job to break the news.
"We had to identify Larry as the one who actually passed away from the fire. That was very disturbing to see anything like that especially being a family member and a close brother," said Randy. "Very hard to see something like that. I don't wish that upon anybody."
The Gilletes say they had a few people tell them the response to the fire was delayed that night, but they did not give it much thought after the wake and the funeral. It wasn't until CNYCentral called and revealed the results of the internal investigation done by the Commissioner of 9-1-1 that anyone told the Gillettes there had been a delay of nearly five minutes in dispatching the Baldwinsville Fire Department.
In a review of the call, the supervisor of shift operations noted this timeline:
At 2:03:38, Gillette tells 9-1-1 there is smoke in his apartment.
At 2:03:44, the call is upgraded to "residential fire" by the call taker.
At 2:03:56, Gillette says he is trapped.
At 2:07:53, the 9-1-1 call taker hears a loud noise and then an alarm. In her statement to investigators, the call taker says Gillette told her something had exploded and something was exploded.
At 2:08:20, police arrive on the scene and report heavy fire from Gillette's second floor apartment.
At 2:08:38, the county dispatcher calls out the Baldwinsville Fire Department to go to the scene.
According to internal documents, from the the time the 9-1-1 center upgrades the event to a residential fire at 2:03:44, it is 4 minutes and 54 seconds before fire engines are dispatched to Gillette's apartment.
In a sworn affidavit, 9-1-1 Commissioner William Bleyle states, "In the history of 911 there is only one other incident that resulted in a fatality where the delay in dispatch may have contributed to the outcome." That was the 1998 Lincoln Park Drive fire in Syracuse where several children died. In that case, a grand jury investigation revealed a 9-1-1 employee was asleep and failed to dispatch the fire department.
COMPLAINTS ABOUT HOW THE CALL WAS HANDLED BEGIN TO EMERGE
While Gillette's family grieved their loss, an internal document shows officials at the dispatch center began a review of the call. The review was dated Nov. 29, 2012, the same day of the fatal fire.
"When I reported to work at [2:45 a.m.], I got the feeling of some grumblings from the dispatchers working that something didn't go well," Mike Cramer said in his Quality Assurance Review.
In the report, Cramer detailed the chain of events leading up to Gillette's death, making note of every second between the call being received and the dispatching of firefighters.
"In my opinion, the upgrade of the call type from the call taker and the notes entered on the event should cause any fire dispatcher to send a structure response immediately," he said in the report.
He went on to say:
Again, this call on the dispatch side should have been upgraded and re-dispatched much sooner. There is way too long of a delay in notifying the FD of the call change.
BALDWINSVILLE POLICE AND FIRE
Gillette lost his life that night, but the fire also put several other people in jeopardy. There were the two members of law enforcement who made a heroic effort to enter the burning apartment. One was an Onondaga County Sheriff's Deputy the other was Baldwinsville Police Officer Corey Coakley.
Baldwinsville Police Chief Mike Lefancheck looked back at the response in 2012 by reviewing the police report.
According to Lefanchek, officers grabbed towels and a blanket and tried to use it as a shield. At the top of landing they were pushed back by heavy flames and began to the resident at that point. Lefanchek says this is when the officers had to retreat and Officer Coakley slipped and fell. He says her injury ultimately forced her to seek medical attention at the hospital. But, before having any concern for the injury they went to the back of the residence. They overturned a picnic table to reach the second floor window, the deputy threw her baton through the window to reach the man and they tried to get him to jump out of the window, Chief Lefancheck said referring to the report.
Over the last three years, Chief Lefancheck had not been informed of the nearly 5-minute dispatch delay as determined by the 9-1-1 center's internal investigation. "At the time I recall talking to the officers if memory serves me correctly. There was some initial confusion about what was going on inside the apartment," he said.
Current Baldwinsville Fire Department District Chief Tom Perkins recalls the night of the Conifer Village Fire. He remembers it started as a medical call for the rescue rig, before being upgraded to an apartment fire. "One of our guys got in and got him out," Perkins said about rescuing Larry Gillette. "He was burned pretty bad. The ambulance was right there, loaded him and right away and took off."
Until we told him last week, Chief Perkins was not aware the dispatch delay was nearly 5 minutes long. "Fires today double in size in thirty seconds. It's been proven they double in size every minute, "said Perkins. "It was pretty much what we would call a flash fire."
A year-long internal investigation ended in December 2013 with two people being punished for the nearly 5-minute delay.
Dispatcher Marybeth Pazaras was given a Written Reprimand. She is an 18-year employee of the Emergency Communications Center. A review of the internal investigation and other court documents shows she "continues to assert that she acted appropriately and would not do anything differently," according to internal documents. In one of several statements she wrote, "My actions were within guidelines for dispatching a call."
In the days immediately following the fire, Dispatcher Pazaras offered a six-line handwritten statement of what happened in those early morning hours of Nov. 29, 2012., according to internal documents.
Call came in as DIFB. I dispatched Baldwinsville Rescue. Notes were unclear as to what was going on. Sent a TA over to call taker to see what was going on. Then I saw the note of alarm going off so I sent the response for a structure fire. Then I left for the night.
ONONDAGA COUNTY RESPONSE TO REQUESTS FOR INFORMATION
The administration of Onondaga County Executive Joanie Mahoney and the 9-1-1 Emergency Communications Center have refused to release the recordings of the emergency dispatchers at the 9-1-1 center communicating with police, fire and ambulance in the field on the night of the fire despite our repeated requests over an 8-month period using the Freedom of Information Law.
9-1-1 Commissioner William Bleyle ran the investigation into the dispatch delay in the deadly fire. He has not agreed to be interviewed for this story. The County Executive's office has not returned phone calls related to this story.
Dispatcher Marybeth Pazaras was contacted by telephone and reasserted her position that she followed proper protocol that night. She stands by her actions despite a CSEA union arbitrator agreeing with the outcome of the internal investigation by the county.
Since the fire, she has filed a complaint alleging she was discriminated based on her gender. In a separate lawsuit in federal court, she is claiming the county retaliated against her for filing the gender discrimination complaint. The New York State Division of Human Rights found there was not enough evidence to support her discrimination claim.