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The original item was published from 8/31/2020 5:17:26 PM to 9/1/2021 12:00:01 AM.

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Posted on: August 31, 2020

[ARCHIVED] Loudoun County Releases Significant Incident Review of Goose Creek Drowning

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During the Tuesday, September 1, 2020 Board of Supervisors meeting, the Loudoun County-Combined Fire Rescue System (LC-CFRS) is scheduled to present the findings from a review of the June 4, 2020, incident response to the drowning of 16-year-old Fitz Thomas at Confluence Park, where the Goose Creek meets the Potomac River adjacent to Leesburg’s River Creek community. The Board requested the presentation following the completion of the significant incident review, which is a long-standing, standard LC-CFRS procedure following incidents of this nature. 

“It is important that the community know all of the facts surrounding this tragic incident,” said Board of Supervisors Chair Phyllis J. Randall. “We asked Fire and Rescue to report back to us on this because we must know what happened so that the county and members of the community can take steps toward preventing it from ever happening again.”

The report being presented to the Board—titled Perdido Bay Terrace Significant Incident Review (PDF) after the name of the road that leads to Confluence Park—includes an overview of the June 4 emergency, details of the responses by Loudoun County and Montgomery County, Maryland first responders, and a comprehensive list of policy changes, recommendations and safety initiatives that have already been instituted as well as those that are in the process of being implemented to increase the efficiency of multi-jurisdictional incident responses in or around the Potomac River.

On June 4, 2020, first responders from Loudoun and Montgomery Counties were dispatched to assist with a reported drowning near the confluence of the Goose Creek and Potomac River. Firefighters arrived at the scene to find an unresponsive teenage male with CPR in progress. Fire and rescue personnel immediately assumed patient care and transported him to Inova Lansdowne Pediatric Emergency Room. Tragically, Thomas could not be resuscitated.

“We continue to extend our deepest condolences to the Thomas family and to all who knew and loved Fitz,” said Loudoun County Combined Fire and Rescue System Chief Keith Johnson. “We recognize how difficult this incident has been for our community; we have been committed to closely examining our emergency response and we are publishing this report in a transparent manner so that everyone can review exactly what happened.” 

A significant incident review team that included staff from LC-CFRS and Montgomery County Fire and Rescue Service (MCFRS), was developed to conduct the analysis. The team conducted a thorough review of all incident details, policies and available technologies for both Loudoun County and Montgomery County Emergency Communications Centers (ECC). The team carefully reviewed and analyzed a wide variety of data and materials, including, but not limited to:  

  • 9-1-1 call audio recordings;
  • Written statements provided by LC-CFRS personnel who worked the incident;
  • Existing policies and procedures addressing emergency responses along the Potomac River;
  • Procedures for the dispatching of mutual and automatic aid resources between Loudoun County and jurisdictions along the Potomac River;
  • Mutual Aid Response Agreements between Loudoun County and Montgomery County; 
  • Current and past practices regarding Potomac River responses;
  • Training requirements for ECC staff;
  • Staffing and organizational structure of both ECCs;
  • Phone calls between the two ECCs with respect to this incident;
  • Radio traffic in each jurisdiction; and
  • Records and notes from each jurisdiction’s Computer Aided Dispatch (CAD) system.

The significant incident review highlighted technology challenges associated with calling   9-1-1 from locations that are close to jurisdictional boarders. Due to the incident’s proximity to the Potomac River, 911 calls from the June 4 emergency scene were received by ECCs in both Montgomery County and Loudoun County. Each of the 9-1-1 calls made during the incident originated from cellular telephones, requiring the cellular routing technology to provide location information. When a call is initiated on a cell phone, the cellular tower sector presenting the strongest signal to that phone—usually the closest one pointing in the direction of the caller—will receive the call and route it based on the number dialed. The 9-1-1 call is then delivered based on the physical location of the cellular tower and sector receiving the call, not the caller’s actual location. During the June 4 incident, efforts to determine the victim’s actual location contributed to a delay in dispatching Loudoun’s first responders.

The significant incident review also provides details regarding response times following receipt of 911 calls. The first 911 call was received by Montgomery County at 5:48 p.m. on June 4, approximately five minutes after Thomas was noticed missing by his friends, according to the caller. Montgomery County first responders were dispatched within three minutes and arrived at the Potomac River approximately 15 minutes later at 6:04 p.m. Loudoun County received its first direct call from the incident scene at 6:06 p.m. Loudoun call takers experienced a delay in dispatching rescue crews due to their inability to obtain a physical address or known location of the incident, which was needed to load it into the CAD system and route responders to the correct location. Loudoun County dispatched rescue crews at 6:16 p.m. and they arrived at the scene eight minutes later at 6:24 p.m., which was approximately 18 minutes after receiving the call.

Between 6:05 p.m. and 6:35 p.m., several other 911 calls were received by Montgomery and Loudoun ECCs during which dispatchers attempted to identify the precise location of the incident and guide first responders to the scene. Dispatchers in the two jurisdictions also repeatedly communicated with one another in an effort to share information, transfer callers and identify whether Montgomery County requested a response by Loudoun County. The significant incident review shows that the delay in determining the precise location of the incident from callers and the protocol that emergency responses to the Potomac River are within the jurisdictional responsibility of Montgomery County were among the factors that affected the overall response.

“While our review shows that staff in Montgomery County and Loudoun County properly followed existing policies and procedures, this incident also revealed that we need to amend Potomac River response procedures to ensure the most appropriate response, which we have already started to do,” said Johnson.

Several changes to the department’s 9-1-1 practices were made immediately, including the implementation of a dual dispatch policy that requires 911 operators to automatically send fire and rescue units any time a call for assistance on the Potomac River or its tributaries on the Virginia side is initiated from Loudoun County. This includes water rescue units if the victim is not confirmed to be out of the water. Additionally, Loudoun County’s ECC has completed upgrades to the 9-1-1 system that will assist telecommunicators in obtaining more accurate location information for 9-1-1 cellular calls.

In addition to the findings listed in the significant incident review, the report also includes more than a dozen recommendations to improve policies and procedures, staffing levels and training that will strengthening multi-jurisdictional emergency communications and incident responses along the Potomac River. The recommendations include enhancing 9-1-1 technologies, better documenting points of interest and vehicle access along the river, expanding 9-1-1 operator training and providing safety and prevention education through community outreach to keep Loudoun residents safe.

The significant incident review findings and recommendations serve as principles on which to improve the effectiveness and capabilities of Loudoun County 9-1-1 operators when handling incidents with all of the county’s jurisdictional partners. The policy changes already placed into action, along with the implementation of the recommendations contained in the review, are designed to enable LC-CFRS and MCFRS to communicate more efficiently and provide more coordinated responses to incidents in and around the Potomac River in the future. 

The September 1, 2020, Board of Supervisors meeting begins at 5:00 p.m. and due to the COVID-19 pandemic, will be conducted as an electronic meeting. Officials encourage residents to watch or listen to the meeting remotely. The meeting will be televised on Comcast Government Channel 23, Open Band Channel 40, and Verizon FiOS Channel 40 and livestreamed at The Board Room in the Loudoun County Government Center, 1 Harrison Street, SE in Leesburg, will be open for anyone who wishes to attend the meeting in person, with social distancing measures in place. 

The 77-page Perdido Bay Terrace Significant Incident Review and LC-CFRS presentation to the Board will be posted online with the Board’s September 1, 2020, packet materials.

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