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Consultant: Tech Errors like the ones in Kyle Plush case 'not uncommon' in 911 call centers

Posted: 3:07 PM, Apr 13, 2018
Updated: 2018-04-14 13:19:49Z
Report: Tech, human error led to boy's van death

CINCINNATI -- A preliminary investigation reports both technical problems and human error may have played roles in first responders' failure to locate Kyle Plush Tuesday.

According to documents from an internal review obtained by WCPO, the 911 operator who answered Plush's second emergency call said she couldn't hear him. 

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Plush, 16, was found dead in a minivan near Seven Hills School hours later Tuesday night. In one 911 call, he said he was stuck in a van outside the school. In the second call, he described the make, model and color of the minivan where he was trapped and dying.

Investigators don't believe there was a failure in the phone system at that time, so it's not clear why the second operator couldn't hear Plush. But the 911 operators' computers experienced trouble "around that same time frame," one of the internal documents states. The operator said her screen froze, preventing her from properly documenting the call. 

"Having a computer system within the 911 center freezing up or locking out is not uncommon," emergency dispatch consultant Dave Warner said.

TIMELINE:  What happened the day Kyle Plush died?

Still, the operator tried sending a text message to Plush, asking him for the address of the emergency. She tried calling him twice, records show. He never responded.

That operator's supervisors found her work in that incident was "unacceptable," according to one of the internal documents. Police Chief Eliot Isaac said Thursday that she was placed on administrative leave. 

"Something went wrong here, and we need to find out why were weren't able to provide that help," Isaac said. 

RELATED:  As Kyle Plush pleaded for help, why didn't officers find him?

After Plush's first call, the 911 operator used cellphone GPS information to point police officers to the thrift store parking lot across Red Bank Road from the school. Plush was within feet of those coordinates. A quality assurance report shows that the first operator didn't note that she heard Plush banging and screaming in the background.

Two Cincinnati police officers arrived about two minutes later, but said they didn't see anything. Officials haven't said exactly where the officers searched. They tried calling Plush's phone, but he didn't answer. 

It was then that Plush called 911 the second time. 

"This is not a joke," he said. "I am trapped inside a gold Honda Odyssey van in the parking lot of Seven Hills. ... Send officers immediately. I'm almost dead."

Plush's words were picked up by the recording, even though the 911 operator said she couldn't hear any sounds on the line. 

RELATED:  Sheriff: Deputy never looked in Kyle Plush's van

A few minutes later, a Hamilton County deputy called in to the emergency dispatch center to say that he had also looked for the caller, but didn't find anything. Chief Deputy Mark Schoonover said on WLW radio Friday that the deputy looked into a van, but it wasn't the right one. 

"He did look into some vehicles. He looked into a van, but he never looked into the victim's vehicle," Schoonover said. "He never located that."

Cincinnati police investigators who reviewed security camera footage also said the deputy looked into many vehicles, including a van, but never made it to the far part of the parking lot.

Instead, a family member found Plush dead inside the van at about 9 p.m., according to police. Hamilton County Coroner Lakshmi Sammarco said he died of asphyxia caused by chest compression. Officials haven't yet said what pressed so hard into Plush's chest that he suffocated. 

Isaac, Sheriff Jim Neil and Prosecutor Joe Deters have all ordered investigations into what happened. 

Chris Carver with the National Emergency Numbers Association said it's rare for a 911 center to experience a serious failure. 

"Unfortunately, when we see critical failures the thing that is consistent among those scenarios is often times it's more than one thing that led to that scenario," he said. "It's almost never just one thing. It's almost always two or three or four things."

Carver and Roger Hixson, the association's technical director, only spoke generally and not on the particulars of this case. But Hixson said a review of Cincinnati's 911 call center would be helpful.

"I'm going to be really interested in how this turns out," Hixson said. "Some of the evidence indicates a problem in one area, a problem in another area."