City of Hartford After Action Report Motor Vehicle / Bus Accident Interstate 84 Westbound Saturday January 9, 2010

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1 Eddie A. Perez Mayor City of Hartford After Action Report Motor Vehicle / Bus Accident Interstate 84 Westbound Saturday January 9, 2010 prepared by: Daniel Scace Region 3 UASI Projector Manager CRCOG Regional Training Coordinator Carmine Centrella CRCOG Homeland Security Planner January 15, 2010

2 After Action Report Disclaimer This report is a written record of an After Action Review conducted to examine first responder issues and actions and in no way an investigation of accident cause and / or determination. 1

3 I 84 Bus Incident January 9, 2010 Incident Summary On Saturday, January 9, 2010 a school bus from the Greater Hartford Academy of Math and Science picked up 16 students and a teacher at 15 Vernon Street in Hartford to bring students to Farmington High School. A collision occurred between the bus and a Volvo station wagon as they were traveling West on I 84 just West of exit 45 (Sisson Ave), causing the bus to go off the highway down the embankment impacting the ground approximately 50 feet below. See Figure 1 for a bird s eye view of the scene. Students and the teacher on the bus were thrown around in the bus causing multiple injuries. A passer by called 911 generating the response timeline below. NOTE: Cellular 911 calls are received by the Connecticut State Police (CSP) and relayed to local departments as needed Caller to CSP 911 states bus went down the embankment right after the Sisson Ave exit 0809 CSP relays 911 information to Hartford Emergency Communications Center 0810 Hartford Fire Department (HFD) Enroute 0814 Emergency Medical Service (EMS) Enroute 0815 HFD Arrived (Ct State Police On Scene) 0819 EMS Arrived 0822 CMED Notified 0833 First ambulance transport 0838 First ambulance arrives at hospital Last patient arrival at hospital Figure 1 Bird s Eye View of Bus Crash Location 1 There is conflicting data between dispatch agencies, but it was not noted as critical to analyzing the response during the AAR. Logs available for the AAR included HARTBEAT Fire and EMS logs, and the CMED event summary. 2

4 Participating Agencies Law Enforcement Agencies (ESF 13) Both the Connecticut State Police (CSP) and Hartford Police Department (HPD) assisted in the response. Per protocol the CSP is the lead agency for interstate highway incidents. The HPD assisted primarily along arteries off of I 84 for traffic diversion. During the course of the incident, including traffic management throughout the day, CSP had 14 units involved and the HPD had 2 sergeants and 7 patrol units involved. Their goals were to maintain safety, assist responding units as needed, begin the incident investigation process, notify Ct Department of Motor Vehicles and Department of transportation (CSP), manage family and media arriving near the accident scene, and assist in tracking who was being transported and to which hospital. HPD dispatched units to support patient flow at the hospitals, except for John Dempsey Hospital (they were not aware of patient transport to this location). The CSP supported the Incident Commander s request to shut down the West bound lane of I 84 to enable a better response for the multiple casualty incident response. Fire Agencies (ESF 4) The Hartford Fire Department (HFD) established unified command at the scene. The first arriving Chief assessed the scene and immediately requested additional units. The next arriving Chief was briefed, assumed incident command for the fire role and the first Chief on scene assumed the role of Operations Section Chief. Their goals included responder safety, supporting patient care and maintaining span of control. Responding HFD units included the following; E2, E5, E1, E14, E7, E11 T1 C2, C1 L3, L6 V80, V9, V81 EMS Agencies (ESF 8) EMS units from AETNA, AMR, AMR Waterbury, and ASM supported the response. First on scene was an AETNA supervisor who became the lead for the EMS response. During his initial assessment he identified the situation as a mass casualty incident (MCI) with 4 Red, 4 Yellow and 9 Green patients. EMS goals were patient care, safety of responders and patients, triage, maintaining an accurate log and efficiently staging EMS resources. EMS providers used the SMART triage system. SMART tags were supplied by HFD. Responding EMS units included the following; AETNA 223, 216, 231, 221, 216, 211, 234, 225 AMR WATERBURY 381, 316, 315 ASM 519, 503, 504 AMR 917, 914, 910, 934, 912, , AMR Car 7, 514, 510 and 512 were included in CMED logs. 514, 510 and 512 were cancelled prior to arrival. 3

5 Hospitals (ESF 8) Participating hospitals and number of patients received include; Saint Francis Hospital (SFH) 7 patients Hartford Hospital (HH) 4 patients Connecticut Children s Medical Center (CCMC) 6 patients John Dempsey Hospital (JDH) 1 patient Dispatching and Notification Agencies CSP Troop H Public Safety Answering Point (PSAP) received the cellular 911 call and coordinated with Hartford Emergency Communications Center (ECC). Coordinated Medical Emergency Direction (CMED) was notified by ECC and provided EMS dispatch and hospital coordination per established protocols. After Action Report Goals and Objectives Agencies and jurisdictions striving to improve performance and achieve excellence in emergency response and preparedness should critically assess real life incident response actions. This assessment process starts with a professional review of each incident or event, focused on performance, to facilitate continuous improvement in the quest for excellence. Such a review was conducted on January 14, 2010, in the City of Hartford, CT related to the car vs. school bus motor vehicle accident which resulted in one fatality and numerous injuries. The objectives established to achieve this continuous improvement goal are as follows: Establish an agreed upon incident time line Identify involved agencies / organizations and their role Identify response strengths and challenges Identify areas for improvement or change (Captured as lessons learned in this document) Identifying Strengths and Challenges Discussion: The review included incident time line, agency role and responsibilities; polices, processes, and procedures; communications; and interagency coordination. From the beginning all AAR participants expressed how well all agencies and personnel worked together in a coordinated effort. Cold temperatures, snow and ice covered topography, and dealing with injured students and subsequently family members who responded directly to the scene are conditions which can easily stress and overwhelm response resources. The strengths identified by participants for roles, responsibilities and procedures included: Receipt of accurate dispatch and incident location from CT State Police (no hunting for the MVA on the highway) All responders worked to manage the scene within their respective roles without question. Incident command was initially established consistent with ICS and NIMS 4

6 Hartford Fire Department practice of transferring first arriving District Chief to Operations Section Chief upon the arrival of the second arriving District Chief who then assumes Incident Command EMS supervisory personnel assumed lead roles either through ICS direction (EMS command ), or ad hoc, e.g. staging, and loading Use of passenger / student manifest by Greater Hartford Academy of Math and Science The challenges or gaps in this area included: Even though Incident Command was established, no Scene Safety Officer was ever designated by the IC Hartford Fire Department declared an MCI to Hartford ECC but the declaration was never relayed as such to CMED North Central EMS supervisory personnel wore multiple hats due to day of week (Saturday) and lack of on duty company administrators The strengths identified for communications and interagency coordination included: As mentioned previously all agencies worked in a coordinated effort on scene Hartford Police Department coordination with CT State Police for traffic diversions onto City streets Collaborative decision to completely shutdown West bound lanes of interstate highway to maintain scene, and first responder safety Hospitals received early notification of multiple patients and triage type, e.g. reds, yellows, etc. It should be noted there was no specific discussion regarding the use of interagency radio frequencies, or technologies (Inter City radio, CSPERN, RAFS, etc) other than the Coordinated Medical Emergency Direction (CMED) network itself. The challenges or gaps related to communications and interagency coordination included: Only one CMED hand held portable radio was on scene This CMED portable was assigned to a med channel whose line of site repeater could not be reached (Med channel 5) from MVA location. EMS supervisor states he was unable to communicate on the assigned frequency Even though hospitals received early notification of event they still did not have a clear picture of what happened, or mechanism of injury. It took multiple radio patches from individual transporting ambulances before at least one hospital really knew what happened. This gap affects the fluid notification of hospital resource needs, and situational awareness across multiple hospital / agency locations First responders did not take full advantage of triage tag numbers to better track patients to hospitals Communications Lessons Learned Communications at large events such as this incident are usually highlighted as an area for improvement whether it is failure of a system, lack of familiarity of interoperability options, or limited use of available interoperability technology. In this instance the field of operations took place outside and all operators and operations, except for inside the school bus, could be seen. There were no in building coverage issues, and in the worst case scenario all communications could take place face to face for on scene tactical operations. In fact the majority of on scene communications were face to face. 5

7 One issue raised during the review was the inability to effectively communicate patient information from the scene to CMED and hospitals. In particular the lack of more than one (1) CMED hand held portable radio caused delays in getting information out to the proper receiving units until ambulances were actually transporting. A CMED portable would have allowed EMS personnel serving in loading, or triage operations to transmit information ahead of actual transport. This information lag did not produce any untoward patient affects or outcomes, but it would have been extremely useful for CMED to better assess patient to hospital assignments. Additionally the more information hospitals receive ahead of time the quicker they can determine hospital resource needs and in hospital resource availability as well as alerting on call personnel. Concomitant with the issue stated above is the noted lack of initial communication between EMS units and CMED in general. As an example, per CMED review the first EMS unit to make contact with CMED was actually the third unit to respond to the MVA. The on scene CMED portable was utilized by AETNA ambulance supervisory personnel operating either inside the school bus or just outside serving as the EMS operations lead. The issue reported for that communication element is that the radio could not reach out from the scene. The portable was assigned to Med Channel 5 and it is uncertain as to whether the issue was location of the medical channel repeater, the topography where the radio was being used, i.e. bottom of highway embankment, or a combination of both. Follow up with CMED indicates that they could hear communications from the AETNA portable but it did seem to drop out on occasion. Additionally, CMED did not make the med channel assignment for the portable; instead it seems that the third arriving unit stated above transferred their assigned channel to the AETNA portable. The opportunity to learn from the stated communication issues includes but may not be limited to: Reassessing the need and value of CMED portable radios Assure all appropriate response personnel are aware of and trained in interoperable communication options Continued outreach and training to regional interoperability options and technology Protocols and Procedures As stated earlier it appears that individuals worked well together during this event. The area for improvement or potential learning could include taking advantage of continued NIMS and ICS training opportunities, especially practical applications in operations based exercises. This builds proficiency, and understanding as well as increasing individual and agency comfort levels in the appropriate application of command and control for larger operations. It was noted that all practitioners may not be aware of the most recent release (January 2009) of the Region 3 MCI Protocol. This protocol details threshold definitions, communications, and resource allocation strategies for multiple casualty events. Again it is noted that this gap did not produce any untoward patient outcomes, but in this instance would have aided in developing situational awareness, better determination regarding resource needs and maintaining fluid notification and response mechanisms. Per the Region 3 MCI Protocols once an MCI is declared it is then CMED s responsibility for resource allocation and assignment based on requests from the scene and not the individual EMS dispatch centers. 6

8 Hartford Fire Department representatives stated (verified through audio tape) they declared an MCI event to the Hartford ECC, but in review of CMED audio tapes that declaration was not relayed as such. The opportunity to learn from the issues stated above includes, but may not be limited to: Review of Region 3 MCI Protocols by appropriate CMED and regional EMS representatives for effectiveness Continued outreach to all stakeholders of protocol existence Region 3 MCI Protocol training for appropriate staff and personnel Inclusion of Region 3 MCI Protocols in both discussion and operations based regional and local exercises SMART Triage Tags It is noted that the Hartford Fire Department carries the statewide SMART Triage tags on all response vehicles. This is identified as a best practice and aids in the establishment and sustainment of triage efforts. This is especially true if responding EMS units do not have a sufficient quantity of tags on individual transport ambulances. That said the triage tags were not used to their full advantage for tracking of patients to receiving hospitals. This created some confusion as to where patients were transported in the earlier stages of the incident. This confusion can amplify resource needs if multiple police personnel are deployed to ascertain / verify patient identification and location. The use of names and respective tag numbers would have aided in the process of tracking patients to hospitals. The practice of using the tag number 3 in and of itself can be extremely beneficial for tracking patients especially if patients have no other identification with them, aka John/Jane Doe. The school bus had a student manifest which is another best practice, which in conjunction with on scene verification of identification and assigned tag numbers provides an effective means for tracking patients and important triage information while maintaining patient confidentiality. This practice can be utilized for assigning pre hospital information to a tag number when relayed to the receiving hospital. This better prepares the hospital for that specific patient so there is minimal time spent on reviewing which patient is tied to which prehospital report. This is extremely important if multiple patients arrive simultaneously, or in close proximity to each other. The triage tags also contain bar coding. When fully advantaged this technology option can be used to enhance situational awareness, seamlessly transmit patient information 4, (and track patients from first EMS arrival right through final hospital disposition. The opportunity to learn from the issues stated above includes, but may not be limited to: Deployment of triage tags to all appropriate response units Continued triage tag training to include designation of recurrent day to use tags regardless of event 5 Investigate regional sustainment program for triage tags 6 Make final determination on deployment of electronic patient tracking 3 Each tag has a unique/distinctive sequential number printed on it 4 Depending on bar code scanners deployed, pictures of patients and injuries can be sent to hospitals before the patient is transported 5 E.G. Triage Tuesdays This builds familiarity among EMS and hospital personnel 6 CT Department of Public Health has initiated the use of the SMART Triage tags on a statewide basis along with distribution of tags to EMS units 7

9 Use of NIMS/ICS Coordination of the response during this incident was accomplished smoothly and efficiently, but not necessarily using all of the recommended NIMS and ICS structures and terminology. An example of an ICS organization is shown in Figure 2 and the titles of ICS supervisors are shown in Figure 3. Typical regional responses do not delve into large ICS organizational structures because response scenarios beyond a local response requiring multiple agencies and/or jurisdictions are rare. In those instances where multiple agencies and/or jurisdictions are involved there are often issues related to the structure and communications across agencies, but they are dismissed as not impacting on the effectiveness of the response. As regional response agencies become better trained and participate in more regional responses it is important to utilize the standards outlined in NIMS so a common expectation for multi agency and/or multi jurisdiction response is maintained. Example 1: In this incident, it is not clear what the EMS supervisor s assignment was. Was he assigned to Unified Command as the EMS representative or was he assigned as the EMS Branch Director? Example 2: Use of 10 codes is common in local jurisdictions because it is widely understood by each department and serves the organizations well in day to day operations. Use of 10 codes is contrary to the NIMS requirement to use plain language when a response goes beyond the local department to the multi agency realm. The opportunity to learn from the issues stated above includes, but may not be limited to: Attempt to clearly establish Unified Command if it is the intent. The initial IC can easily do so by relating it via a simple statement (consider use of common frequencies such as Intercity) such as Unified Command is established for the I 84 Multiple Casualty Incident with Hartford Fire, Connecticut State Police, and Emergency Medical Services. Reinforce use of NIMS terminology and positions (Such as EMS Branch Director) during regional responses and exercises Encourage departments to use plain language for all responses to instill habits that support NIMS compliance during multi agency/jurisdictional responses First Responder Picture Taking Use of photos and/or video at an incident scene is appropriate and provides excellent documentation of actual scene conditions for future reference and/or relaying of information for situational awareness for the response. They are also valuable resources for after action reviews but should be taken by responders who are authorized to document the scene and are properly equipped. Use of phone cameras by individual responders, whose primary duties do not include taking pictures to document the incident, can create problems including interference with primary first responder duties and the distribution of scene information and pictures that are inappropriate. The opportunity to learn from the issues stated above includes, but may not be limited to: Departments should consider establishing policies related to taking pictures or videos at the scene of an incident 8

10 ICS Organizational Components Incident Commander Public Information Officer Liaison Officer Safety Officer Operations Section Planning Section Logistics Section Finance/Admin. Section Staging Area Resources Demob. Service Branch Support Branch Time Compensation Claims Branches Air Ops Branch Situation Doc. Commun. Supply Procurement Cost Divisions Groups Strike Team Task Force Single Resource Medical Food Facilities Ground Support Visual 2.22 ICS Fundamentals Review Version 2.0 Figure 2 - ICS Organization Components ICS Supervisory Position Titles Titles for all ICS supervisory levels are shown in the table below. Organizational Level Title Support Position Incident Command Incident Deputy Commander Command Staff Officer Assistant General Staff (Sections) Chief Deputy Branch Director Deputy Division /Group Supervisor n/a Leader Manager Strike Team/Task Force Leader Single Resource Boss Figure 3 ICS Supervisory Titles Visual 2.31 ICS Fundamentals Review Version 2.0 9

11 Use of a Passenger Manifest The Greater Hartford Academy of Math and Science provided a passenger manifest to first responders making it much easier to establish accountability for all of those involved in the incident. The opportunity to learn from the issues stated above includes, but may not be limited to: Maintain a list of all passengers that is readily available to first responders in the event of an accident while transporting students or others for a group activity Incident Information Management and Situational Awareness Ensuring incident related information is available across the spectrum of users is a major challenge. When responders and providers have all the information they need to make critical decisions related to their actions, the outcomes will be the best possible outcomes available. This high level of situational awareness is built via the use of many different sources of information, including personal observation, information relayed by others on scene via radio, cell phone or mobile data terminal (computers), information relayed by dispatchers (generally second hand information relayed to dispatch by others) via available communication devices, and by face to face communications. Systems used to gather information to enhance situational awareness are referred to as common operating picture (COP) systems. On scene information during this incident was managed via radio or face to face communications and was generally well managed. Areas where information was less effectively used involved the flow of information to the hospitals and the universal distribution of critical information to all agencies that needed the information. Saint Francis Hospital received the bulk of the patients (7). They understood they would be receiving several patients, but did not initially know an approximate number of patients, the cause of their injuries, or the extent and type of injuries. This situation put them in the position of having to guess what their Emergency Department requirements were. Compounding the situation for them was the fact that this incident occurred on a Saturday morning when it could be problematic to staff up for a large surge need. The hospital staff built their situational awareness over time as they got individual reports about the condition of each patient. This piecing together could have been done via a COP system that transmitted to all involved the nature of the accident, extent and number of injured patients, and perhaps even included pictures of the scene. The other piece of information that was not relayed to all was the determination that the incident was classified as a mass casualty incident (MCI). Incidents classified as MCIs invoke a unique set of protocols at CMED. These protocols were not put in place because the MCI classification was not transmitted to CMED. The opportunity to learn from the issues stated above includes, but may not be limited to: Regionally, consider developing a COP system As noted in Protocols and Procedures : review of Region 3 MCI Protocols by appropriate CMED and regional EMS representatives for effectiveness. In addition, continue to develop a regional awareness of the need to transmit this type of information. 10

12 After Action Review Summary This tragic accident resulted in one fatality. Responders managed the response well and were recognized and thanked by the Greater Hartford Academy of Math and Science for their quick response, professionalism and the compassion they exhibited towards the passengers injured during the accident, and their families. By all measures this is a success story for the Connecticut State Police, Hartford Fire Department, Hartford Police Department, Hartford Emergency Communications Center, CMED and all EMS responders. What is very meaningful is that those involved chose to review their response via a formal after action review process. From the regional perspective, we are hopeful this will help institute this review process across the region and lead us all to a more effective response system. The benefit of this process can be recognized by noting the number of items that did not impact negatively on the response to the incident, but did not follow the expected path. This identification of issues, related directly to answering the question what would you do differently the next time? will lead to a more effective and efficient response, and ultimately, enhance public safety across the region. The authors, the Capitol Region Council of Governments, and the leadership of the Capitol Region Emergency Planning Committee sincerely thank Katherine McCormack, City of Hartford Emergency Management Director, for setting up the AAR and all who participated in gathering the information for this report. 11