thank you very much for having us here today uh  today we're going to present our post incident   analysis report about the Brook Hollow Apartment  fire today with me I have a couple of the uh   members of the team first uh Vernon Champlain  I have uh Brian Brian Nelson right here and   uh Scott rickham uh those are were four of the  total of nine of us that worked on this uh this analysis all right so today I'm going to run you  through um just a high level of our approach uh   uh and our our assignment and approach to this  uh Pia um we're going to give a little bit of   the report outline which you have um we're going  to review the incident and we're going to review   the instant analysis and recommendations agency  by agency we're going to talk a little bit about   key findings and then talk about how we move  forward as a public safety system so first of   all why are we here we're here because of the  Brook Hollow Apartment fire which occurred on   October 13 2023 that tragically took the life of  Miss P leeski but it also injured several other   occupants and could have harmed many others  including First Responders so our assignment   was a thorough evaluation of the public  safety system uh that responded to this fire   uh to understand first of all their policies  and procedures and uh those meeting exceeding   and how do they compare with other jurisdictions  as well as looking specifically at the uh these   agencies uh how they performed on this incident  and how their actions may have affected the   incident outcome and finally our our task  was to identify a strategy to and create a   plan to improve the outcomes of the public safety  system as a whole uh to restore public trust and confidence our report that you have uh identifies  overarching themes and gaps in administrative   operational processes as well as where the  agencies and uh policies and procedures are   considered adequate as well right so this is  not just pointing out where it doesn't work   but where it is uh where it does work for for  all the agencies involved we analyzed a number   of documents ments here uh on the left hand  side of the screen um policies and procedures   organizational Frameworks um of again all the  public agencies involved which were the Witchita   fire department the Witchita Police Department uh  cedri County emergency communications as well as   sedra County uh EMS uh we went uh uh we went and  also looked uh uh at the building code and looking   at the was the building constructed correctly  at the time of construction um we also looked   at actions that were taken uh before uh the  incident as well uh that may have impacted the   incident itself we conducted two site visits and a  number of follow-up interviews and phone calls uh   with all of the agencies and all the entities  you see here on the right hand side of the screen there's of course limitations to  any analysis um we relied on the available   information and data that we were provided um we  B we we stand behind the findings that we present   to you in this report um We believe We collected  them with discretion investigative diligence and   professional respect our findings of course  are subject to change if additional relevant   and factual information is provided I will say  that uh through the assistance of Dante Martin   and Rusty Leeds at the county and Dante Martin  here at the city uh they were our Liaisons to   this and anything we asked for they got us access  to um and if we weren't given the information we   were um told why it didn't exist essentially  so we don't expect uh additional information um report structure itself uh goes into  the background of all the agencies uh just   for record um it then goes and talks about the  incident overview itself we then like I mentioned   go through in the report uh agency by agency  uh the analysis of the actions that they took   talks we look and review their s sogs and Sops  um and we find recommendations for each agency   to improve finally the moving forward section is  our conclusions uh it provides a path forward um   uh for this public safety system to improve  its response to uh citizens of Witchita as   well as the county itself and then there's  a number of appendices at the back of the report we're going to get into the incident  next but be but first we want to remind U   as we talk about this in detail we want to  remind everyone about what is the brookal   apartment complex how is it laid out that  will play into some of the challenges that   uh all the public safety agencies found when  they responding to this fire so the brookal   apartment complex was at 8165 e Central it  has a single vehicle entry and exit in the   north uh east corner uh to the complex the  complex itself the apartment building itself   is comprised of 12 twostory buildings they're  Garden style apartment so two above grade and   one half below grade being the garden apartment  and there's approximately 72 units in the complex I will point before moving on from this  slide um that there is a wood fence that   surrounds the entire north west and south  of this property the only opening in the   fence uh uh is to the Northwest where  there's a person siiz opening uh to   allow people to go to the north but other  than that the only vehicle access in and   out of this complex is to the Northeast  on the even on the morning of October   2023 there was a very strong wind coming out of  the uh West Northwest uh Focus here on building   300 because that's uh where the fire occurred  which is in the northwest corner of the apartment complex so building 300 uh is comprised of  six units about 580 feet each uh they're all   single bedroom units in this building two  per floor like we mentioned every unit is   provided with an ABC dry chemical fire  extinguisher by the property management   as well as a smoke a working smoke alarm  uh the fire alarm there is no fire alarm   system there was no fire alarm system at the  building like automatic fire alarm system at   the building at the time of the fire and  there is uh there was not one required we   did as I mentioned uh mabcd gave us access to  the original building permit and the original   building drawings they they had they had that  information and um uh building was C constructed   in 1977 likely constructed to this 1973 or 1976  uniform building code and uh we found that the   building was constructed uh to code at the time  of construction both Fire and Building Code if   constructed today sort of a side note uh witcha  would require uh sprinklers inside the building   however this fire started technically  outside of the inhabited portion of the building now we're we're going to get into the A  Narrative of the incident so at about 3:58 a.m.   Miss peski calls 911 she tells the call Taker and  dispatcher that her apartment is on fire that she   lives at the Brook Hollow Apartments she's unsure  of the building address but she's in unit 306   and provides her name Miss peski asks for help 48  seconds later there is not another word uh discern   word coming from that phone call to 911 within  a minute of the phone call starting the the   witto fire department is dispatched by uh Cedric  County imun cedri County emergency communications   dispatch a minute later the residents in  unit 304 right below unit 306 where this   peski is they report the fire as well at 4:15 the  engine engine 15 who's already out of the station   uh coming down Rock Road uh requests a  second alarm they tell us they can see   they can see the fire coming down Rock  Road at that at about that same time   when they're requesting that second alarm for  the first time uh Miss peski uh her 911 call ends I think it's important to note that before  any fire companies are on the scene two residents   from unit 304 do uh and two residents from unit  305 jump from their respective Windows to to to   self- evacuate and save themselves one resident  from unit 303 runs down the exterior stairs   through the fire uh and one one resident from unit  301 escapes through their front door uh which is   the garden level after and that happens all before  the fire department's on scene so they don't know   they don't know that at about 403 engine 15 and  Squad 15 are on the scene they report heavy fire   from the second floor they start a fire attack and  search operation couple minutes later Battalion 3   takes command there's a call from a friend of the  resident in unit 302 which is the uh garden unit   on the right side here in this pictogram which  would be the northwest corner um says that that   that Resident cannot self- evacuate uh over the  several minutes additional fire companies arrive   dispatch at uh 407 reports uh on the  radio that uh on the Ops radio that   person is trapped in unit 302 medic  2 cedra County Emergency uh or EMS   medic 2 hears that and responds says I'm  responding and send two two ambulances with me so the fire department is reporting that  fire is in front of the units 30 uh 304 303   305 306 so that that at the stairway Landing  inside the interior or the exterior uh exit   stairway portions to that stairway a couple  minutes so this is a few minutes after the   fire department re uh arrives about 410 to  413 portions of that stairway roof collapse   on engine 15 and Squad 15 they transmit  a Mayday over the radio command reports   everyone out and that they're going into  a defensive operational mode residence in   unit 302 is evacuated by Squad 14 and Tower 3  as the stairway is collapsing so the stairway   starts to come down they're actually coming  out the doorway of 302 they have Embers coming   down they they take a step back they pause let  things settle and then get that resident of 302 out at that time or during that time the incident  command conducts a personal accountability report   which is required for as what you would do  especially with a Mayday making sure you   have all your firefighters accounted for  at about 4:20 the emergency Communication   Center at Cedric County uh finally transmits  that second alarm that was requested before   before 21 fire companies realized that they  hadn't finished checking the top floor of   this building and they go back to check  the top floor which you know had not been   before that stair collapse in Mayday so in this  421 to 424 time frame rescue 2 breaks the bedroom   window which uh uh the upper right window in unit  306 um and three firefighters enter uh the bedroom   they find Smoky and hot conditions um to the floor  um but after searching the bedroom they don't find   anything so they continue two firefighters move  into the living room area and continue search SK two firefighters searching uh identifies a  bathroom and in that bathroom he finds a victim   in the bathtub three firefighters work to get  that victim out of the uh bath out of the out   of the bathroom back into the bedroom and out  the window to a firefighter uh on engine 10   who's at the top of the ladder ready to receive  receive the victim once down the ladder engine 10   uh starts CPR on the patient which is Miss peski  at about 4:26 a.m. at about 4:34 scems starts to   transport their first patients they've received to  the hospital which is not miss peski yet at 4:36   the fire investigator arrives on scene from wiah  about 4:32 uh SCS is now connected with the witcha   fire department treating Miss peski so before that  it was just the Witchita fire department treating   Miss peski in Total EMS uh treated  triage treated and transported up to   four or four patients to the hospital  which included Miss peski who they   transported starting at about 4:54 a.m.  and they arrived at the hospital about 8   minutes later scems transported the last  patient to the hospital just before 5:00 a.m. the investigators at this point as the  fire is contained and controlled uh the fire   investigators start to photograph the scene and  document the scene they leave the scene at about   10:10 in the morning final time that day and at  about 11:05 engine 15 was the last uh witch fire   department unit on the scene and they cleared  the call so at that point there's no other uh   uh fire department or apparatus or Personnel  on the scene according to information we have so this is an introduction to the analysis of  each agency's actions um after a comprehensive   review Jensen Hughes found no single point  of failure of any of the agencies involved   that could solely be attributed to the fatality  of Miss peski peski pesi instead Jensen Hughes   found a number of systematic shortcomings  that when combined mind contribute to an   unorganized rescue effort had these findings and  shortcomings not occurred it would have provided   Miss peski with a better chance of early rescue  and subsequent increased potential for survival   provided she was still alive the last known  time that we know when she was alive was when   she stopped speaking 48 seconds after she had  her 911 call 48 seconds after her 911 call was   received which occurred before the witch fire  Department was dispatched her call disconnected   from 911 before which to fire department even  arrived on scene Jensen Hughes cannot conclude   that the shortcomings that you're going to  hear about today and they're in this report   that are identified of the public safety  system you cannot we we could not conclude   that the shortcomings identified would have  absolutely changed the outcome of this fatal incident we're going to get into  into the emergency communications portion mayor members of the council thank you  for having me here I'm Brian Nelson I'll be the   technical aaon for Jensen Hughes and we'll talk  through some of the technical um operations of   the Sedwick County emergency communications  center on the day of the incident uh first of   all let me talk a little bit about the dispatch  technology used at that facility um we in the   industry consider um them to be using best of  breed system systems a couple of examples of   that are the 91 phone and the radio system  are systems from Motorola everybody's heard   of Motorola their CAD is a Enterprise grade  um system from Tyler Technologies well known   in our industry and the uh voice recorders that  are used to capture the audio that we hear are   from nice so very very good systems Sops and  S so's um we reviewed and compared those uh to   the appco and Nina standards those acronyms are  listed at the bottom of that slide if you needed   to know what those meant and again we looked at  those at the time of the incident we understand   there has been some updates and changes to some  of those Sops and S so's um since that time um   they were thorough and well organized and up to  date as far as the training of the dispatchers um   the sedge County emergency communications center  operates in a call taker dispatch uh environment   where a call taker generally triages the phone  call from the from the 91 caller and passes that   to the dispatcher for the response to get to the  level of being a dispatcher um it takes a couple   of months of training as you can see uh to be the  call taker you start with a four-week Academy and   then they start on the job training once they  complete their on the job training for their   call taker duties from 3 to 6 months they start to  train as dispatchers and they first trained to be   fire dispatchers and they call that fire or they  call that dispatch level one after 9 to 12 more   months or 9 to 12 months of total training they  become fully trained dispatchers that can work on   all disciplines police Fire EMS and dispatch it's  important to note that there were some concern   about staff levels at the time of the incident  we do know that they were operating on minimum   Staffing um we will talk a little bit more about  what that means as we continue here but just as   a note it's noted that SED county has been  aggressively looking to uh that higher pay   raises uh pay rates for employees and have  been trying to recruit and keep retention of employees some of the human factors as  they relate to technology and operation   Miss pesty's 901 call uh was answered uh  according to appco standards uh within the   time frame that's listed in the uh the  graph over to the right other 911 calls   that came into the center were also handled  and triaged appropriately according to appco standards calls from unit 304 and for the person  calling on behalf of the resident 302 again were   both answered within the standard benchmarks of  the app Co standard that you see listed there   moving to the audio recording Miss madesi's 91  call audio recording was reviewed uh and we do   know that the call taker dispatcher indicated that  he could not understand the apartment unit number   that she provided and therefore did not provide  this information to the witcha fire department   hearing and understanding speech are affected by  many factors we looked at age genetics environment   cognitive fact actors language and others Jensen  Hughes listened to the recording released and we   can hear and understand Miss bed's provided unit 9  unit 306 twice now as a technology leaz on I will   have to note that the call recording comes from  a different level of the call processing then   what the dispatcher hears and on the next slide  we're going to talk about the Dual headset that we   say that could could be a contributing  factor to not understanding that unit number okay so again to continue on with  the hearing and understanding speech is   also affected by the technology the quality of  the audio the quality of the playback and the device Jensen Hughes can confirm that  the recorded 911 call Audio released from   SEC EC dispatch is of higher quality than  what the call Taker and dispatcher here   is sitting on the console we reviewed the  technology and Hardware associated with the   live call taking dispatching recording  and Playback we determined again that   the quality of the audio recording is  pure meaning digital recorded from the carriers and is captured prior to the hardware  that's connected to the headset we listen to   live calls and listen to the recorded playback  of those live calls what can be heard in the   recorded audio is not the same as what is  heard on the headset and we will refer to   that as the backend the differences in the  backend recording additionally there is a   feature called instant recall that allows the  call taker dispatcher to play back the audio   from the system in which it was provided  uh unfortunately it was not used in this   incident this could have have allowed the  unit number to be understood and relay to   the wiah fire department and again this uh  instant recall was available on the 91 phone system uh delay and dispatching the second alarm  John already mentioned the timeline of which the   second alarm was called for and wasn't dispatched  till many minutes later uh we learned that the   delay in the dispatching uh was a cad issue  the computer A dispatch system that they used   to provide that second alarm or provide the units  to go to the second alarm several dispatchers and   a supervisor were unsuccessful in assisting the  dispatcher in dispatching the second request or   this the second alarm another dispatcher across  the room overh heard the conversation and was able   to get the recommended fire unit recommendations  to appear in CAD and then finally dispatched the   alarm this issue was brought to the attention of  the SC EC Administration later that morning and   they found that multiple dispatchers on multiple  shifts could not recall how to do that dispatch in   CAD within days of the incident the administration  arranged retraining for all staff members on this issue okay uh and then the the final technology  challenge that we uncovered were the Dual headsets   so the dispatchers and call takers in uh SED  County emergency communications wear double   headsets and this is um I've been in public safety  technology for 30 years and we have not normally   seen that we don't see that in in any other  area or any other uh dispatch centers that I've   witnessed before so again to reaffirm listening  and understanding to different sounds coming in   from each year dichotic listening is what they  call that was thought to be one of the um issues   that created confusion for the dispatchers in this  incident so what we did is we sat down the members   of the Jensen Hughes team sat down at the dispatch  councils and listened to the dispatch what the   dispatchers hear and we can concur that what we  hear in the double headsets was very difficult   and almost impossible to completely comprehend uh  both with preference to one ear seeming to always   have given the U what you can hear regardless  SCC dispatch has operated this way with the   Dual headsets for many years and undoubtedly  the call taker dispatchers have become better   at diotic listening through practice and with  that we will turn it over to Vern for the fire portion afternoon Madame mayor members  of council Vernon Champlin Jensen Hugh   this portion of the presentation we're going to  look at the um witcho fire department and their   operational response um related strategies and  tactics of the incident um we started off this   assessment by looking at policies and procedures  uh we evaluated wit fire department policies and   procedures against NFPA standards and other  department policies and procedures as well   as industry best practices um we found that  the Witchita fire department's operational   manual which will be referred to as the M  um was thorough well organized and up to dat   however we also found um numerous operational  policies that were not followed during this incident the um this presentation is um it's  difficult to give from an operational fire   ground operational perspective in the fact that  um there's lots of layering of of things going   on simultaneously and so in an attempt to um  separate that and kind of present it to you   we've identified these five areas uh being uh  deployment water supply and fire attack search   and rescue command and control and then mday and  so uh although I'm going to speak to these kind   of individually you're going to hear some of the  same comments maybe at different portions of the   presentation because they uh are dual related so  NFPA 1710 is the um internationally recognized   standard regarding organizational deployment of  fire suppression operations emergency medical   operations and Special Operations to the public  by career fire departments um there's two primary   components in that standard um in which that we  looked at one being total response time and one   being total effective response Force um there are  benchmarks associated with total total response   time uh regarding the first arriving engine time  the second arriving engine time and then the total   effective response Force arrival time secondly  the total effective response force is made of   of a number of firefighting Personnel  identified to complete critical task   analysis on a fire ground based upon General  Hazard types so regarding a garden level   apartment NFPA is identified um minimum uh  total and I strongly say minimum the minimum   total effective response Force as being U  28 firefighters if an air Ral device is uh response in our assessment we found that  the witch fire department's response to   this incident met the Benchmark standards  for response time for each of uh first   second arriving units as well as the total  effective response force and we found that   the witto fire department assembled the total  effective response Force within the Benchmark   Standard Time shown there in the tables it's  worthy to note that the witcha fire department's   deployment to this apartment structure fire is  the same regardless of of if it says trapped or   not trapped essentially if a structure fire  comes into a garden level repart apartment   the the Run card and the dispatch response to  that is the same same number of personnel same   number of apparatus strategic priorities are  set by The Incident Commander and Associated   task once they're on on scene um that's to be  determined by The Incident Commander once they arrive the employment there's a lot of information  here on this slide um I'll note the picture on the   left is essentially um our best um culmination  of data and information related to the actual   incident uh scene where units were positioned  the black circles with the number uh in the   center are it's the arrival order in which  those units arrive to scene uh you'll also   notice the green dotted line that John mentioned  earlier that um is a fence around the northwest   South sides it's a six foot privacy fence  you'll also notice the hole cut in the fence   uh by firefighters there's also an opening in the  northwest corner of the fence you'll also know um   you'll also note that there's a significant  number of Witchita fire department apparatus   on the North and northwest corner uh on the other  side of the the privacy fence um this is because   the site condition itself is is so restricted  and limited uh inside uh the apartment complex   boundary um and then finally I'll point out  if you notice there at the apartment complex   there's the swimming pool it's actually where the  flag is located the Google pin just to the East   and a a little bit north you'll notice the fire  hydrant location uh of a single fire hydrant uh   located here within this property so with that  information and we take it and apply it to this   table on the right you'll notice that there's  essentially four columns um across the top the   um the engine arrival the truck rescue arrival the  squad arrival and the BC and other unit arrival   it has the um the rows sorry the columns uh  are further divided into the specific unit and   then the arrival time and you'll notice next to  the unit there's a number in parentheses that's   the number of personnel on that apparatus it's  important to note that there was actually the   seventh unit on scene um is actually the first  unit to establish uh command uh the operations   manual references initial uh incident command as  well as incident command and in this particular   case it was actually the seventh arriving  unit before somebody actually took command   of the of the scene you'll also notice that uh  following the um 10th arriving unit there's a   total number of 28 uh firefighters on scene  the reason that's important is back to that   total effective response Force so um there at  uh 28 firefighters were on scene in six minutes   from the dispatch time and I I think I'm very  comfortable in telling you that from a National   perspective 28 firefighters on scene is a very  very good response time for that a number of   people that's a it's a it's a very strong response  you'll also notice that when the second alarm was   in fact dispatched um between rows 17 and 18  there were actually 41 firefighters on scene   um well beyond the minimum standard of 28 by the  time the dispatch um call the second alarm was dispatched after deployment we'll talk about  water supply this woodframe non-s sprinkler   high density residential unit is served by a  dead-end water M with one fire hydrant on a   deadend road these conditions alone warrant  extensive pre-planning however the Witchita   fire department's provided pre-plan is weak the  first arriving engine did not lay a supply line   per the operations manual thus requiring others  to handj large diameter hose a timec consuming   process the operations manual directs the second  arriving engine to not stage and immediately   establish a water supply however the second  engine N9 arrived and staged at a hydren on   Central and engine 14 the third arriving engine  actually initiated the water supply plan engine   14 first first attempted to access from the west  and was met with the privacy fence so they went   around to the north and came in the Dead End Road  um and attempted to take the hydrant within the   complex however truck five had parked in front of  it truck five was deploying their Outriggers and   they were directed by engine 14 to reposition  thus causing additional water supply delays the initial Crews deployed three attack lines  two 2 and 1 half inch lines and a single inch   and 3/4 line simultaneously from engine 15  600g tank without a continuous water supply   being established fire suppression was stalled  and Crews were put at risk when Engine 15 ran   out of tank water firefighters were in the  ma were in the stairwell without water when   the roof partially collapsed and the MayDay  was transmitted the rapid advancement up the   stairwell suggests that they that the crews were  operating in fast attack rescue mode which is an   option within the operations manual despite the  fact that the fire Attack Mode was declared by   Squad 15 which actually requires an i or a rick  per the operations manual continuous water supply   was eventually established from the onside  hydrant by engine 14 The Chosen approaches to   water supply and fire attack impact did the timing  in which the victim may have been removed from her   apartment recommendations consider limiting the  number and size of handlines permitted to flow   water from a booster tank before a water supply  is established I also want to take a second here   to apologize that I'm reading this to you as you  know we presented this information to the county   this morning and um out of respect for the city  of Witchita um I read these notes so that not to   go off on additional items so I'm reading them  equally the same to you so I know that we were   all taught in school that's not a great way  to present but I'm doing it on purpose we'll   move on now to search and rescue heard the  operations manual searches should generally   begin closest to the fire area and work back  from there let me say this firefighters are   trained to save lives and they should do this  regardless of what dispatch says or or rely   on what a panic civilian says interviews with the  Witchita fire department confirm that firefighters   knew there was a high life Hazard on Floors  above the first floor when they arrived given   the time of day they assumed that the apartment  was occupied until it was confirmed not to be occupied with a single way in and out from a  single stair Tower vent enter search or otherwise   known as VES is an effective method to conduct  quick searches per the the operations manual but   there is no indication that vs occurred  anywhere and especially not nearest the fire first 911 caller was Miss badesi in  unit 306 and it's important to note that   despite what some of the news media has said  that she did not report she was trapped she   actually asked for help I know that's  a difference in terminology but there's   actually that terminology means something  in the dispatch policies too the difference   between asking for help and asking and saying  you're trapped approximately 3 minutes after   witch to fire arrived on scene SED County  Emergency communication announced over the   oper channel that one person was trapped and  that was reported in by a friend from person   in unit 302 some fire companies arrived and self-  assigned or were directed by the command to search   uninvolved buildings before Crews completed  the search of building 300 where the fire was located during interviews those Crews stated  that they believed other Crews were searching   building 300 you may want to flip back to your  site map I'll try to explain building 300 to the   east of it is building 21200 to the south of it  is building 41100 through reviewing reports and   radio communications we had confirmation Crews  were in fact searching building 204 400 and   there was reports of crew searching the backside  unsure in our analysis what the backside means   but we assume it was probably building 1100 and  1200 so if you look at your map that'll make more sense heard the operations manual during a Mayday  no fire ground assignment should be abandoned The   Incident Commander is responsible and will direct  and or redirect operations it is is reasonable to   assume that the in Incident Commander would need  some time to gain control of the situation and to   start working through the mday checklist and I  didn't go into it in this presentation here but   the um operations manual is pretty specific on  assigning resources to deal with both incidents   simultaneously search and rescue was eventually  rep prioritized after the MayDay was stabilized   and the primary search was completed for the  remainder of building 300 including units 305   and 306 Miss peski was found unresponsive in 306  by rescue 2 and brought down by engine 10 since   sedc County EMS is not automatically assigned  to a structure fire response unless someone is   reported trapped which at fire must be prepared  to triage and treat victims until they can be   transferred to EMS recommendations here Searchers  should begin closest to the area of fire for the   operations manual and an immediate arrival of  truck companies to a residential structure fire   should employ prioritize search and rescue  as an immediate action of opportunity that   targets a known or high probability area of a  trapped subject and that's out of the operations manual now to command and control command  and control of an apartment fire involves   the organized management and coordination of  firefighting efforts through the incident command   system this is a national system which defines  a clear hierarchy of the chain of command it   begins with a size up where the Incident Commander  conducts an initial assessment of the situation to   gauge the fire's extent identify potential hazards  and understand the building's layout effective   resource management is critical as personnel and  equipment must be allocated appropriately with t   with priority tasks assigned to Firefighters and  coordination with additional emergency response   services once on the scene the emergency command  The Incident Commander determines the incident   strategy which may include coordinated ventilation  fire attack and search and rescue priorities the   first arriving units did not assume command  as they engaged in fast attack search mode   which is permitted by the operational manual  however as additional units arrived on scene   no one established initial command six units  were actually on scene before command was   eventually established by the seventh arriving  unit which is Battalion 3 communication between   incident command and fire ground operations  is essential to communicate those incident priorities once interior searches were underway  neither an internal initial rapid intervention   crew nor a rapid intervention crew was formally  established as required by the operations manual incident Commander's action or inaction can  have a significant impact on the outcome of   any incident in this incident command was not well  organized and appeared to be more reactive than proactive five examples of deficient command and  control actions at this incident include directing   an engine that was staged at a contingency  water supply per the om to reposition and   search an uninvolved building number 200 units  were allowed to freelance without a clear   assignment or incident coordination this is how  we ended up with people on the the backside quote   on backside of the building allowing companies to  search uninvolved buildings before the high prior   priority area closest to the fire when the MayDay  occurred the operation was switched to defensive   pulling all all fire ground both fire attack  and search and rescue operations out of the   building to focus on the MayDay deprioritized  deprioritized search operations and did not   manage the MayDay and Tac radio communications  in accordance with the operations manual did   not broadcast critical fire incident benchmarks  one way that incident command kind of controls   the management of an incident is through the  use of benchmarking those benchmarks include   things like water supply established primary  Search complete secondary Search complete fire   under control we're not communicated over the  radio per the OM recommendations include things   like examine recent fire incidents to determine  if incident command is typically effective this   was a one-off failure to communicate fire scene  benchmarks result in the lack of adequate fire   ground management announce incident man  benchmarks to the dispatcher via the Ops Channel speak a little bit about the MayDay  and U maydays are are fairly close to um   Everybody in the fire Services Mayday  is how we take care of our own Mayday   training and procedures and it's how we  care for our own a Mayday is an emergency   incident concerning occurring within emergency  incident it represents the critical moment   when a firefighter is in distress and requires  assistance due to life-threatening circumstan   es Mayday must be treated with the same level  of priority and structured response as the   initial incident a dual focus is necessary to  manage the MayDay while maintaining the ongoing   incident ensuring a comprehensive response  to both challenges when the MayDay occurred   there was no initial rapid intervention  crew or rapid intervention crew formally established incident command did not upgrade  the alarm when the MayDay occurred as required   for the OM there was no direction from command  regarding if the MayDay incident was to remain   on the TAC Channel and other units were to  change channels per the omom which resulted   in numerous times of other units walking  on the the emergency radio traffic of the MayDay command did not provide status  updates as the in incident progressed   on the Ops channel nor did command announce  when the MayDay was complete as required by the OM the handling of the MayDay impacted the  timing in which the victim may have been able   to be removed from her apartment although the  MayDay was quickly resolved there is evidence   that managing a Mayday is not well practiced  within the witcha fire department incident   command structure or firefighters we interviewed  witch Fire Department firef Fighters associated   with this incident it revealed that most could  not recall the last time a multi-company Mayday   training was completed many referenced their  training academy their initial hir training   academy recommendation conduct Mayday training  but not just simple Mayday training but design   complex training scenarios that include  multicomp operations with search and rescue   fire suppression and rescue operations  being conducted when the simulated Mayday occurs here we're going to move into a slide  outside of my initial five this is the fire   causing and origin investigation and although  the actual cause and origin investigation was   not part of the initial response which is  our primary focus it it essentially is part   of the ongoing incident and so there's a  few items here we'll share Jensen Hughes   was provided with limited information regarding  the investigation findings and recommendations   should be considered as complete as possible  at this time um however the the FIU which is   the fire investigations unit noted the origin  to be exterior stairwell of building 300 in and   around the landing of units 303 and 304 and the  cause of the fire remains under investigation so   without a determinant that could possibly limit  the amount of information they provided us and   so our information again is limited however with  the information we did receive a few photos some correspondents our assessment questions  the fiu's adequate training and   performance of Investigations in accordance with  internationally accepted practices of NFPA 921 and 1033 five examples of inag adequacies that  we notice include seen photography is not   systematic or complete evidence sent for  testing did not include control samples   photographs of samples tested were not  in context exact location T taken no   seed and diagram was provided there was lacking  supplemental reports on follow-up investigation activities origin and cause investigation  report should have been completed by   now even if determined undetermined  with discussion of competing cause hypothesis I would share one of  my bigger concerns is that this   incident was a civilian Fatality and  included a firefighter mday event the   fire investigation unit left the scene 45  minutes approximately 45 minutes prior to   engine 15 clearing the scene I would would  consider that not industry best practiced or normal with that I'm going to turn it back  over to John to take you through the last few slides on to Cedric County EMS um Cedric County  EMS provided triage treatment and transport of   up to four patients as I mentioned before um  the first arriving units on scene did have a   difficult time identifying an area to access the  scene as we've talked about there's one way in and   one way out and a difficult time identifying  victims um this was primarily due to like I   mentioned limited vehicle access um but also the  EMS not being dispatched to fires unless there is   a report of someone trapped so they they're aware  of the fire to be clear they're aware of the fire   and the uh the EMS District Chief is supposed to  listen to the radio to decide if they want to go   on their own uh and once someone's reported as  trapped that's when on a structure fire that's   when they get dis automatically dispatched um  Additionally the triage area was either not set   up or not communicated so um there's radio traffic  where the police are asking dispatch to ask EMS   where should we send patients and EMS says we're  not even there yet I I don't know so the police   send everyone to the incident command which  was a fair decision at that time but we don't   know that there was a triage uh uh area set up  to to focus patients this put all of this put   EMS at a disadvantage um luckily the district  Chief was listening like he was supposed to to   uh radio traffic and he did self-dispatch himself  and and two other medic units um shortening their   response time so they were dispatched but he  actually preempted that and and got everyone   moving quicker I think it's important to note  here that nfba 1710 will bring this up again   and um for a for a a full alarm assignment on  an apartment fire it does require uh a medical   care component that is at least two members  capable of providing uh unseen uh medical   support so that doesn't that's that's help  but it also requires someone to be able to   transport them so currently uh policies  and procedures uh on these fires are not   complying with NFPA 1710 with with providing  uh EMS uh on a as a first due assignment and   that is that is a strong recommendation that  SC EMS provide an ambulance on Fires where   there is high life safety risk specifically  as examples apartment fires or high-rise fires moving on to the Witchita Police Department  uh the police department is also not automatically   do um on structure fires like bralo they're  they're made aware of a standard structure fire   response um uh police department uh played a  relatively small but you know Fair a good role   on the incident when they were called they were  called to assist with a belligerent individual   they assisted as I understand with a little  traffic management uh which is typically what   they do when they're called to these scenes uh  and they did assist the FIU the fire investigation   unit of of the fire department interviewing  uh uh incident victims uh both I think on the   scene and at the hospital but we believe this  is a missed opportunity the police department   they're on patrol 24 hours a day they're on the  street every day all the time they have specific   Geographic areas in which they're responsible for  they know everything about their patrol area if   they were if they were due unreported structure  fires maybe not all of them but certain ones with   proper training they could offer initial size  up they could they can tell you could tell the   fire department through dispatch oh yeah I see the  orange stuff I can respond keep coming or I don't   see anything that doesn't mean the fire department  doesn't keep coming but you know some additional   information before the fire department gets there  from the police department could be helpful they   they could continue with traffic control scene  safety make sure the fire department can get to   the to the scene safely and control the scene they  could assist with learning a occupants of danger   right so the the the witch police Department  with proper training could be clearing people   away from the idlh atmosphere the the the area  that's immediately dangerous to life and health   which is where the fire department should be  operating they could they could be clearing   other apartment areas while the fire department is  focused on the the what their gear is made for and   making those rescues they could also the police  department could identify potential Witnesses   and make other critical observations in case case  the uh incident did become a potential criminal matter strong recommendation of ours is that the  WPD and the wfd work together to develop policies   and procedures uh so that the police can properly  assist on fire scenes and they can actually look   at the uh International Association of chiefs  of police model policy the law enforcement fire   response uh model document as an example  it's a very simple two-page document and   it Prov provides really good guidance on  spefic specific ways the police can assist   the fire department in responding to life those  emergencies uh also equally important the policy   outlin specific actions police officers should  not take when working the scene of a structure fire to our key findings so number one  Jensen Hugh believes that Cedro County   emergency Communications caller dispatcher could  not understand what Miss peski was saying when she   stated her apartment and unit number however  the dispatcher also did not use the instant   recall feature available to replay the audio had  he done that it may have allowed him to better   understand what she was saying and then he would  have been able to relay that information to the   witch to fire department number two the cedra  County emergency communications uh dispatched   the requested second alarm after a significant  delay however we found that the fire department   had an adequate number of firefighters on scene  to conduct fire ground operations of a garden   style apartment before that second alarm was  dispatched number three we found the witch fire   department's decisions associated with initial  attack an uncoordinated search and rescue effort   an effective command and control in addition to  the unfortunate partial collapse of the stairway   and subsequent Mayday delayed search efforts now  in our evaluation we've been highly focused on   what the agencies did and did not do and how that  may have affected the timing in which the search   occurred uh to potentially increase uh the chance  of Miss pes's uh being rescue being rescued and   maybe survive but we cannot ignore factors that  are outside of all the public safety agencies um   because these were also pretty critical factors  the first is that that there was past evidence of   inappropriately discarded smoking materials in and  around building 300's exit stairway prior to this   fire it was a problem uh there this exit stairway  itself its combustible construction its geometry   the wind conditions the morning of the fire were  significant factors that played into the outcome   of this incident we found evidence on Miss pes's  social media in the weeks leading up to the fire   that a smoke alarm in our apartment had  a low battery we know if that detector uh   was working properly at the time of the incident  we also don't know if she replaced that battery   minutes after posting that video in reviewing  the available fire scene photographs provided   by the witch Fire Department fire investigation  unit specifically looking at patterns of fire   impingement on the exterior doors and the  damage to the insides of the apartment units   the door we look at we look at those photos and  and and we see that it seems like the unit of   door 36 may have been open or opened at some  point during a portion of this incident where   other apartment uh apartment unit doors remain  closed and that's by looking at the photographs   that we've we've been given from the fire  investigation unit that fire if that door   is open longer than anyone else's then that makes  that environment inside that unit uh a much more   difficult environment to survive we do not know  how that how the door if it opened how it opened   uh when it opened damage inside that apartment  uh uh and the damage to the door is different   than the damage inside the other apartments and  the damage to their doors if they were opened   Miss medeski decision to retreat to her windowless  bathroom is a contributing factor to her fatality   if we look at fire exposure to the uh adjacent  apartment unit 305 the wind was blowing everything   blowing everything to unit 305 that was a much  more severe exposure than to the 30 unit 306 and   despite that those residents survived they were  injured but how did they survive they found their   way to the front bedroom and they jumped from the  window prior to the arrival of the fire department how do we move forward it's important to state that you  know we've we've been asked to and have   taken a microscope to a post Incident  That's What We you've asked for and so   we're looking at this uh looking at this  with with a microscope with a magnifying   glass um we first have to say that we believe  that everyone involved in the public safety   agencies had the best intent there was  no malale intent here everyone did the   best they could at that time um however  we still find there's opportunities for improvement every Public Safety agency  involved in this we have recommendations   for in this report we have not gone through all  of those uh we would be here for a lot longer um   but every Public Safety agency had a role in  providing a a better incident response uh to this before we can work on those things we need  to work on some underlying challenges the path   forward with cedra County the city of Witchita  and the other local public safety agencies uh   is putting together putting aside differences  working together to develop a working in strong   trusting relationship and rebuild the trust of  the citizens that you all serve there have been   long-standing tensions and animosity like going  back decades between Cedric County emergency   communications and some of the agencies that  serve undermining the trust and respect of   everyone involved to to to to foster a stronger  working relationship and better serve the county   in the city you we have to move past you have  to move past those grievances real imagined   uh focus on building a better foundation  and mutual understanding and trust trust   that everyone is doing the best they  can rather than assuming that they're not public safety system uh public safety system  Services Thrive when there's collaboration between   neighboring agencies driving improvement and  Innovation however in the case of which Tau fire   and police as well as cedra County emergency  communications and their EMS Department the   lack of nearby comparable advancing agencies  Fosters complacency you know wion cedri county   is geographically isolated you're there's  you're the big you're you're the big you're   the the big dogs here geographic isolation these  agencies must intentionally seek out professional   relationships elsewhere that will contribute to  improved Service delivery so outside this area go   well beyond this area to find out what other  people are doing and see if it's what if if   your system could learn something from those  systems a recommendation is that this public   safety system should seek out benchmarking  from other similar systems around the country   and potentially accreditation of these different  Public Safety Systems as methods to continuously   evaluate itself against similar systems finally  the fire department culture and accountability   the fire department appears to lack emphasis on  self-reflection and accountability within its   Culture by fostering a culture rooted in humility  collaboration and continuous Improvement the   department can enhance its services and streng  strengthen its ability to meet the city's needs effectively that we will take questions thank you very much to the team at Jensen Hughes  for the report council members do you have questions vice mayor Balor thank  you well I have a whole bunch but   I'll just um ask a couple so the idea that  POI didn't say the word trapped change the   whole chain of commands of how it should  have gone I would I don't know that if I   was in that situation I would notice a  trapped but is that why medical wasn't dispatched so the word trapped so the word  trapped in dispatching has a specific mean   has a specific meaning and a call taker dispatcher  has to discern whether or not they believe someone   is trapped or not trapped um when I'll use when  unit 302 the friend of unit 302 did not say trap   but they said they cannot get out themselves  and so the dispatcher call taker decided that   that was trapped and that's what initiated EMS  a a a EMS response rather than just monitoring   in the background so to your answer all takers  dispatchers have to determine whether someone is   trapped or not to just suppose that in unit 304  unit 304 occupants called and said hey there's a   there was a lot of commotion in the background  and then their phone line went dead just like   Pei's they had an open phone line just like Pei  did and but they they jumped out the window the   dispatcher didn't know that they continued to ask  what was going on and they didn't get a response   just like POI so they don't know they have to they  have to use context clues to to try to determine   if someone is trapped or not if they're not using  that word specifically M Madam mayor Vernon champ   I um I think I appreciate your question but I I I  also want to make sure that that doesn't become a   rabbit hole the reality is the operations manual  indicates that fire ground operations should focus   on areas that are most immediately dangerous  to life and health it's the reason that fire   ground strategy and tactics are not determined  and communicated from The Dispatch Center to the   responders the responders determine fire ground  priorities in accordance with their policies and   procedures and the incident command whether  that's initial or established they prioritize   that and put resources to that I can tell you  and and every firefighter will tell you dispatch   information is just dispatch information we never  buy or sell the farm on dispatch information it's   it's additional information that's taken into  consideration yes and we always appreciate it   when it's accurate but arguably it's as inaccurate  as often as is accurate so that's why the policy   is specific to say and this is not a policy just  specific to Witchita this is consistent policies   across the country the fire ground resources  regarding search and rescue and prioritization   of incident strategies and tactics occur by The  Incident Commander on the scene okay um thank   you for that um why would you not or when does  the playback option you said they chose or it   wasn't done in this situation what would trigger  someone to do the playback is that something you   do on every call or or please help me understand  that um yeah no you not on every call I mean if   you don't hear something and know that technology  is available to you you would certainly I would   think rely on that I am again a technology person  not a dispatcher I never sat in the seat Scott I   don't know if that's a cue for you to come up  here and kind of suggest what you would do and   we had we had pretty much that same question from  from the County um as someone who sat in that seat   if someone was giving me information and I did  not understand that information could not hear   that information I would use my playback at that  point until I could understand that information   so would you don't know what you don't hear if you  don't correct know right so um I was just curious   about some of them heard the 306 some of them  did not corre from what I understand the phone   call the call taker said he did not hear it could  not understand it at all okay um and then my last   question um is about training it sounds like um  there's a lot of training that uh I'll just speak   to uh the fire department that we are really  lacking um I would hope that we there's a lot   of training that we are up to date on but um does  it appear that there is a significant amount of   training that we are behind on in in all honesty  I looked at one in inent um and so it's hard   for me to make a general statement across Fire  Department training um but I will tell you that in   the analysis of the fire ground operations one so  many policies were not followed so many important   fire ground command and control functions at our  Baseline were um freelance distracted um not well   communicated um I also have have to question just  the local culture not just on the fire department   but across the board of Emergency Services um  the basic professional fire ground Communications   regarding radio traffic um words and methodologies  Beyond even just the benchmarking but there's   there's just such basic conversations of of unit  identification and things that we are all trained   on as hey you it's me types of methodology of  communication on the radio was not followed was   not followed so I give those examples not to  say that Fire Department training in general   is lacking but Fire Department training at  this incident didn't distinguish itself as   um impressive thank you very much council  member hoisel thank you mayor um thank you   guys for all your work on this I appreciate an  outside look uh couple of quick questions here   um when you're talking about the headsets and how  there's a dual headset um what is the purpose for   the Dual headset so in uh SED County Emergency uh  Communication Center they utilize two headsets one   headset for the 911 phone system and one headset  for the radio system um there are some technology   challenges in integrating uh headsets from these  very different uh systems a radio system and a   phone system in my experience in Public Safety  in many areas in in in the country I we have not   I have not seen a dual headset operation that  doesn't mean it it doesn't work but we did see   that there could be some issues with that amount  of different information coming in you know your   both sides of your both sides of your head okay  so it's one ears from one one ear is your N1 phone   call Taker and you have a microphone on that and  so you're speaking to the to the caller listening   to the caller in one ear and out the other ear  you're listening to the uh radio traffic from the   First Responders and you're giving them traffic  through their microphone so there's a lot of stuff   going on okay and that can be integrated into  one head that yes that can be integrated into one   sorry no go Ahad would there be audio Improvement  to put one into one or is that something we just   have to deal with and it's just clearer when we  play the tape back now to the context of improving   the audio from the carrier of the radio to the  headset there are still some technology challenges   in there there's still um some analog to digital  conversions that happen in there that can you know   change the the tone of the radio or or the phone  phone call it's not a a a magic situation to fix   everything but it does cut down on the confusion  that that human has in front of them with all   that information and makes it easier for them to  understand a single thing that's happening and and   they're not missing traffic so what what happens  is the headset becomes active on the communication   that the dispatch is trying to listen to or  communicate on or talk when they switch to the   other one a speaker is presented in front of them  you know just a standalone speaker where they can   hear what's called select audio which is the radio  traffic that they can still kind of listen to in   the background but it's not their focal attention  when they need to focus in on the caller they can   focus in on the caller when they need to focus  in on the radio traffic or the response they   can focus in on that okay thank you for clearing  that up and one thing that will help with that   even if they continue the Dual headset they are  working towards and have been for some time with   uh piecing out call takers only so that beginning  that beginning dispatcher is a call taker so they   have a separate group of call takers so all they  do is take phone calls so they have that single   headset that they are listening to the dispatchers  then would still have that dual headset and if all   of those call takers were busy those calls would  then present to a dispatcher and one of those who   was not busy would take that call so that that  will help if they get that program you know   completely up and working which they're working  to thank you um on the MayDay um what is the   standard operating procedure for that what did we  what did we because it says that during a Mayday   you start treating them the Fallen firefighters  just like somebody who got called in it's like a   the original response yeah so um and I'm I'm just  referring to the witch fire department operations   manual off top of my head now but there's a  there's a clear policy and that some of that   policy indicates that The Incident Commander um  should assign um somebody to manage that Mayday   um so that that essentially has its own Incident  Commander okay there's a component of the policy   that upgrades the alarm to get additional  resources at this particular incident that was   a a a fairly um quickly resolved minor Mayday but  something that was extremely complex could require   additional resources um there's also a component  of the policy that talks about whether or not   um fire ground operation communication switches  to another channel so that the person that's in   the trapped or or or severe condition may not  be able to change their Channel they can have   a direct line of communication with The Incident  Commander assigned to the the MayDay portion um   the so there's a lot of components there  um that that did not happen um one of the   the bigger concerns is even when the MayDay  resolved itself there was no communication   broadcast that the MayDay is over and we are  doing something else um the the operation just   kind of continued to expand and through  interviews we found that as people kind   of looked around there was people just kind of  re-engaging in the offensive fire operation but   there was no real transition um also I guess  if I take a step back the component of going   100% defensive pulling all operations out of  the initial incident and then establishing a   which is the personal accountability report  the par itself took about 10 minutes where The   Incident Commander checked with every unit on the  fire ground including those units on the backside   right checking on everybody but vital time was  passed by and and we didn't we didn't operate   both those incidents simultaneously we stopped  one and did the other and took our eyes off the   primary Ball even though the MayDay is a primary  ball too we stopped the initial operation for the   MayDay okay and that Mayday standard operating  procedure that's in line with the recommend or   the national recommendations yeah mayday mayday  has been a conversation in the fire service for a   number of years now um wiah fire unlike not unlike  every major Metropolitan fire department has a   mday policy um and and at some level there's mday  training um I have not been um I haven't taken the   Deep dive into the Training Division and what that  looks like my comment earlier was just some um   interview feedback that we heard from firefighters  um indicating they had they've done some single   station or single apparatus drills but not complex  Mayday where you're maintaining fire suppression   operations conducting search and rescue operations  a Mayday occurs multiple layered effects occurring   at once okay uh just two other quick questions on  the timeline uh when did Battalion 3 get there was   asked one who essentially took command that was  the seventh unit to arrive on scene and I believe the so I should I so to answer your question  they arrived at 0 40521 which was um about 5   minutes after the first dispatch five minutes  after the first call so that kind of goes back   to the fact that even though there were  seven units on scene um before incident   command was established those seven units  arrived very quickly I don't remember if I   told you all this or if it was to the group  this morning but having having seven units   on scene um in the first six minutes is is  very good like that's a very good service   where the service started to fall apart  is that there was no strategic fire fire   ground prioritization occurring and there  was freelancing going on of people doing   all kinds of things without a clear defined  objective to to search Rescue of the closest Hazard so that yeah that sounds like they  were there maybe two minutes after the First   Responders got there right around so engine 15  arrived on scene at 4 it's pretty small here on   my 402 so yeah um 3 or 4 minutes after the first  driving okay and I think that when I when I say   that it's even though the operations policy  does allow for the first arriving pumper to   engage in fast attack right that is accepted what  the policy doesn't do is allow um six other units   after that to arrive and not establish command  okay apprciate that um an EMS arrived at 432 John that's not on my list  here that's in your front timeline yeah it's kind of General on the timeline so says 4:32 so medic 2 to respond at 4186 with two  more ambulances they're on the scene sorry I apologize so at 407 dispatch reports trap person  302 medic 2 hears this and responds and asks for   two additional ambulances at 407 but I'm not sure  oh 418 I think is when they were on seat okay all   right appreciate that yep sorry yeah 4186 is  when we reported them in on SE all right that's   all I have and this and this timeline in the  presentation here is a is a condensed versus   what's in the report okay thank you council member  Tuttle thank you and I attended the presentation   this morning so a lot of my questions have been  answered by my colleagues at the county and then   today but um thank you for the present ation  and when we use Jensen Hughes for our Police   Department I think it's been very helpful we've  had good feedback from police good feedback from   the community um and I know we're going to have  more questions but uh city manager Leon if I can   ask you a question and tell me when I'm wrong  which is often I know but with the witw police   department after we received the report we  put together an implementation committee and   then decided you know next steps and how to move  forward it sounds like we did a lot of things well   um both the county and the city and there's  some things also that can be improved as with   any situation do you have any thoughts or a very  initial I know it's preliminary but thoughts of   of Next Step because I think you know when we're  talking with community members when people are   going to start asking us questions and they will  um I would like to know kind of you know where are   we going to go from here and how are we going to  use this Rich information to make sure that we're   just continuing to develop as a fire department  and and then also for the county thank you   thank you mayor uh council member that's a great  question um we all just received the report today   so still formulating our thoughts but I really  see two levels of review and implementation the   first is the fire department itself and  we need to look at the recommendations   the observations and then recommendations  made by Jensen Hughes as they pertain to   training incident command and some of the other  issues that were uh listed for fire department   but then we also have to engage with our  partners so it's a little bit like um what   they did uh that we've done with County before we  have to get together with the county and and talk   about EMS portion of this the dispatch portion of  this as well as talked to the Police Department   EMS and police department partner agencies  small recommendations or or not as extensive   recommendations but again what are we going to do  as a team to enhance our operations going forward   so I that's my initial thought is that  we'll wind up looking putting together   for the council a set of uh implementation  strategies based on the recommendations   contained in the report and again at two  levels fire department as well as the entire team I have specific questions I think it might  be for is it yes Vernon so obviously the city   of Witchita main departments regarding this uh  report or which shall fire and which shall Poli   but more pointedly this is about um some of  the procedures regarding the fire department   can you talk about um your most concerning  once again um key findings regarding what you   mentioned were uh what was it so many policies  quote were not followed can you talk about those so I I'll do my best here to get to your question  but I'll come around the barn um when we did   firefighter interviews it's important and I'm  sharing this with you as the city I didn't   share this with the county right the city  fire department is your department when we   did interviews we interviewed I think there  was just over 40 firefighters that was at   this incident that we actually met with and  spoke to and I want to tell you that I walked   away from those interviews impressed by your  firefighters I think you have a very enthusiastic committed aggressive and healthy group of  firefighters I engage with firefighters all   over the world actually and I will tell you I was  impressed by the physical fitness and and passion   of your firefighters to serve this community  that's that's the honest truth and I told   these guys when we left those interviews um I  also believe that there is an existing there's   a condition that exists within the Witchita  fire department that is not unusual to some   firefighters in the fire service we are  the ultimate adapters and Overcomers and   sometimes adapting and overcoming gets the  job done but it creates a pattern of um silo   we'll just do it ourselves everybody  else is wrong and we only know right   because this is the conditioning  in which we mitigate people's worst days I think the components of aggressive  and independent Overcomers contributes to   a very strong type a culture that requires a very  very strong presence of command and control and I   believe that the policies that were not followed  in this particular incident that was identified   were were a result of those two components you had  firefighters that were aggressive getting to scene   and getting it happen and getting it going and  you had independent free bodied adap and overcome   to whatever I see the moment of priority being  and a lack of strong leadership and command and control we also talked about humility can  you talk a little bit more about culture   um obviously you interviewed a lot of the  firefighters um I'm concerned about the culture the nature of the culture  in the business itself is aggressive   it's independent it's problem solvers and  sometimes we have to check ourselves to be collaborators I think one of the hardest  things that I heard from a firefighter   during the interviews and it wasn't just one  firefighter it was multiple firefighters when   asked about why were you searching buildings  uninvolved with the fire repeatedly I heard   we thought thought somebody else was there  was not a culture of Abandonment there was   not a culture of irresponsibility it was  a culture of assumption that somebody else   was taking care of the priority and they were  coming in later into the incident and backing   up the incident but unfortunately what was  happening is that repeated we just spread   resources thinner and thinner from where our  attention and priority operation needed to occur maybe this question is for the  city manager what has happened   since the incident regarding um one  of these recommendations which is culture that's question is probably best  answered by the fire chief there has been   I think as a result of the Jensen Hughes  work there's been some more reflection on   um actions taken by the department not  just for this incident but also in terms   of command um uh incident command and the the  need for um I think a more aggressive incident   command but again the chief can talk a  little bit better about that than I can M mayor city council city manager um yes the  W fire department has instituted U officer   development um which encompasses a toz um  all the different aspects of leadership   of uh collaboration of cooperation of incident  command both on the fire ground administrative   uh the whole gamut um we're in the early  infancy stages of it um we have um uh put   um one uh group of individuals through it to  identify the gaps we're currently working on   those gaps um and uh the game plan is to uh  provide that training U throughout the the   department that's one aspect of it um we're  recently also um working on our collaboration   and a partnership with our County Partners um  started a um just an opportunity where we put   um it's a program in which we've allowed  um some um exposure to each other um at   our field level um we also started a meeting  on a weekly basis with our field supervisors   and their supervisors um both um from the  individuals that have participated um to   this point plus the supervisors plus the directors  it's been phenomenal and open up tremendous lines   of communication uh those are the two things  that we've worked on um specifically at this point council member Tuttle thank you and  and chief I might just add when we're talk   about cultural overall and one of the comments  from um Jensen Hughes was that the you know the   health of our office of our firefighters was  um noticeable during the interviews getting a   head knot I I caught it right um and chief snow  and um President Bush with iff 135 and I and as   well as other Community Partners are working  on creating a culture of Wellness um and some   of the things that we're trying to do regarding  cancer screenings sleep hygiene um other things   that are in contributing factors to the health  of our firefighters so that they can serve but   then also so that they can be protected and so  I do think that you know it's one more thing   that's going to help the culture overall and  help us maybe to you know just make sure that   we're addressing the needs of our firefighters so  thank you oh the other thing mayor woo I forgot   was we've also implemented a monthly training uh  where we send the training out ahead of time to   each one of the battalions and then we bring  them down unannounced uh just randomly and   we have the battan chiefs actually um sit in and  view the training um so they uh they're observers   they're not actually involved in it and that  way then they can identify by um and see what   we see as far as from the training division  to help um uh improve the skill sets of our firefighters mayor Ballard thank you mayor  thank you Chief uh you just answered um a   couple of the questions just they had mentioned  about um the policies and PR procedures um that   were uh showing concern about not being followed  through um can you address any of the training   concerns that they shared yeah that's what we're  doing through the monthly training um we identify   um some of the gaps that we have and um like  I said we we put it out and then um we give   them a month to train on it individually  each one of those stations and we then we   just randomly bring them down and then we uh  go through that so yeah those are different   aspects that's something that we've never done  before I was going to say with that prior to   the fire or you guys just started doing that we  just started doing it afterwards thank you yes mhm additional questions from Council Members  cenan thank you Chief snow and thank you to the   Jensen Hughes team um moving forward I know you  mentioned the three major challenges of trust   and collaboration enhanced Public Safety Systems  in the fire department culture and accountability   um what are some now that you've heard what  uh Chief snow has said about steps that have   taken since the incident what additional things  do you see uh the city of witch's fire department   um doing in order for us to regain trust and  really have collaboration because I think one of   the speakers mentioned there has been Decades of  animosity and we need to move past uh grievances   how do we move forward yeah I think we've talked  about I mean we've talked talked about this uh   uh that there there really needs to be you know  after I think all parties all agencies digest   what we've said and have questions um it's  definitely worthy getting department heads   uh in a room together um and and maybe with  us or not and to to discuss you know to get   to get past uh some of these things that that were  either uh thought to be true and not true or not   not exactly what everyone thought they were  um and start to work together again I talk   about benchmarking um you know this the growth  of the growth of the sedra County emergency   communications uh dispatch uh Center itself  and emergency communications you know it's   been taking in for years uh it's been taking in  for years uh some of the out you know the smaller   uh communities both on the dispatch side they've  been giving up their own dispatch and giving it   to the commun emergency communications emergency  communications uh e EMS they've been giving up   Ems and now they're handling EMS I think there's  and we we've heard from the fire department that   you know there A lot of times they're going  and and uh attending to EMS calls and waiting   you know waiting for the County EMS so there's  opportunities to free up you know U possibly   free up where the uh County may need some more  EMS uh Staffing and and and equipment to allow   the witch toop fire department to focus more on  firefighting operations than um waiting for you   know waiting on an ambulance a transport vehicle  to take up a patient to a hospital or a shelter or   something like that so I I think first getting  in a room of of the department heads and then   maybe one level down and and and starting to have  conversation about these things again after this   is digested but um there's definitely a lot of  opportunities for for reflection here um and they   benchmarking against other communities elsewhere  um we talked a lot about the siloing the siloed   mentality I feel like it has to do with geography  a little bit um you're the like I said you're the   biggest you're in as part of Kansas you're you're  it so uh reaching out as you know far and wide   and making connections at all levels of  the public safety system to understand what   other people like like which ton CED County are  doing John Madame mayor the it's not written so   clearly in the report but again it's your fire  department and this is the city council so um   in my experience of exposure I would say that  there's great benefits through opportunities   specifically speaking to the fire department um  great opportunities in in working with the Center   for Public Safety Excellence um through accredit  and credentialing uh credentialing of Chief Fire   officers and fire officers and credentialing  of the organization itself in general and the   reality is is the actual designation or the  accreditation component to me is not what it's   about it's about the extensive process of self-  evaluation and organizational evaluation and   the things that are learned through that process  that makes you a better service to your community thank you again to the team um  I see no further questions from   Council Members so I will move to  adjourn this special motion and   a second any further discussion see  none Madame clerk please open the RO motion passes 6 to zero thank you very much