911 Dispatcher Post-Incident Analysis: Additional Considerations

In reading and participating in Post-Incident Analyses over the years, where performance of 911 Dispatchers had come under scrutiny, I noticed that the typical sources of information considered are recordings of telephone calls and radio calls, time stamps, maps of the incident, resources available, resources utilized, weather conditions, organization charts, policy review, training records, and witness testimony. With the advent of Computer-Aided-Dispatch, more management reports have become accessible, depending on what data an individual department elects to collect.

Over this same general time period, we have become more aware of 911 Dispatcher Stress. Not just emotional stress secondary to vicarious trauma from exposure to the trauma of callers and victims, but also the chronic stressors that influence 911 Dispatchers every shift (and, in many cases, during off-shift time).

I was reading a report recently where investigators noted that the 911 Dispatcher involved did not use an available instant playback feature, which might have allowed for an opportunity to possibly get clarity on the involved unit number in a multiple dwelling fire. It was noted that the audio quality in the 911 Dispatcher’s headset was inferior to that on the playback device. Additional training in the use of instant playback devices was recommended. All of this is useful, but it is not sufficient.

Post-incident investigators need to employ retrospective vicarious situational awareness. I know that’s a mouthful, but the concept is key to understanding what happened. In studying a 911 Dispatcher-related incident retrospectively, we need to know what was going on with that dispatcher, during and before that call, and what was going on in that PSAP at that time.

In my view, any time a 911 Dispatcher’s performance is called into question, critical background information should include that 911 Dispatcher’s length of service, length of shift, total hours worked in the previous seven days, amount of time off since previous shift, number of overtime shifts worked in the past quarter, does the 911 Dispatcher work rotating shifts and does the 911 Dispatcher work a second job? In other words, was 911 Dispatcher fatigue a contributing factor?

The National Transportation Safety Board typically takes blood and/or alcohol samples from pilots, train drivers and CDL drivers after an incident. I’d like to see blood testing, not just tox-screens for drugs of abuse, but also related to the dispatcher’s overall health. To be clear, I am not looking for excuses for any sub-par performance. I am looking for possible explanations.

Beyond the information associated with the individual 911 Dispatcher, I’d also like to see information about the working environment in the PSAP at the time of the incident being analyzed. What was radio traffic like? How many active incidents were there at and around the time of the event under scrutiny? Is there more than one frequency being monitored and/or used in the PSAP? And, importantly, how many 911 calls were in the queue?? Because, as I have noted in these articles before, you can’t triage it until you answer it. If I knew that there were units on their way to the scene of a reported incident and there were still phones ringing, I doubt I would prioritize using an instant playback feature over answering a ringing phone. Especially if I thought that the audio quality on the playback would be the same as the audio quality in my headset, through which I could not completely understand the caller.

Since much of the research on 911 Dispatchers is done by 911 Dispatchers who are working towards advanced degrees while they are also working as 911 Dispatchers, a lot of it does not see the light of day via professional journals. The process of professional publication takes time that a lot of working 911 Dispatchers just don’t have. For reliable information about the fatigue-producing effects of shift work and workload on 911 Dispatchers, we must look to other professions.

Nursing has been around far longer than 911 Dispatching and has many discipline-specific journals. Many nurses are researchers. For just one example of nursing research into the effects of shift work, I offer this, from an article in JAMA Open Network, May 4, 2022, titled “Rotating Night Shift Work and Healthy Aging After 24 Years of Follow-up in the Nurses’ Health Study.”

“In this cohort study, rotating night shift work was associated with decreased probability of healthy aging among US female nurses. These data support the notion that excess night shift work is a significant health concern that may also lead to deteriorated overall health among older individuals.”

Another 24/7/365 operation is Air Traffic Control. Here, Air Traffic Controllers have the research and process improvement advantages of a single controlling authority, the Federal Aviation Administration (FAA) and government funding resources beyond that of individual 911 authorities at any level. When it comes to fatigue, the FAA treats it as a serious problem, as seen in an April 19, 2024, memo titled "Assessing Fatigue in FAA Air Traffic Operations.” The memo was in reaction to a report titled, Assessing Fatigue Risk in FAA Air Traffic Operations Report by Scientific Expert Panel on Air Traffic Controller Safety, Work Hours, and Health. From the memo:

"The report raises serious concerns with respect to controller fatigue and off-duty time. Based on extensive research and compelling scientific data, the Panel urges the FAA to quickly develop and implement a strategy to update the current prescriptive policies to address identified fatigue factors, especially to avoid known schedule practices that induce fatigue. Specifically, the Panel suggests the FAA require sufficient time off-duty (e.g., 10-12 hours) before all shifts, regardless of whether controllers are performing operational or non-operational tasks. Also, off-duty time should account for the circadian timing of the shift, where increased off-duty time may be required before midnight shifts."

These two examples tells us something about some of the consequences of working around the clock and working without adequate rest between shifts. There are many others, involving diet, social isolation, and physical and emotional health. We should take what we can use from research that examines specific aspects of other professions that are similar to the profession of 911 Dispatching.

To recap: Anytime there is a 911 Dispatcher post-incident analysis, standard operating procedure should include dispatcher-specific information and PSAP conditions concurrent with the incident being analyzed.

Research from Nursing and Air Traffic Control professions tells us that there are many possible performance-influencing factors beyond those now typically being studied in 911 Dispatcher post-incident analyses.

The idea is not to get 911 Dispatchers off any hook they might deserve to be on. It is to learn more about root causes of less-than-optimal performance. A post-incident analysis may come across these data. But if you are truly interested in getting to the bottom of things, in finding and funding the right fix, you must have an investigative protocol which collects these data in a structured way.

Parts of this article are excerpted from my book 911 Dispatchers Are More Than You Might Imagine?, being released later this year.