As a lawsuit forced the release of more information about what went wrong in the Dane County 911 center the day Brittany Zimmermann was killed, the answer to one question remains elusive:

Why did the system fail?

County officials have said they chalk it up to "an environment in which multiple things are happening" and where screams and sounds of struggle might be inaudible, even though they can be heard on a recording of the call.

They have also said there's no use examining the problem further because the county is making staffing and equipment improvements that could minimize the risk of further errors.

Last week, the county notified the operator of a three-day suspension in connection with the Zimmermann call, without specifying what she is accused of doing wrong.

The operator suggested in a May 3 e-mail to her boss that her equipment was faulty, because she didn't hear the scream and sounds of struggle that police say are on a recording made at the operator's console. Police weren't dispatched until 48 minutes after Zimmermann was killed in her West Doty Street apartment.

County officials deny equipment was the reason the operator couldn't hear a scream on the call.

The computer workstations, last upgraded in 2002 and criticized by the operator, were scheduled to be replaced in early 2008 but won't be in place until early next year.

In a second failure on April 2, dispatch center personnel misread their recording system and sent police chasing the wrong suspects for two weeks. In the discipline letter to the 911 operator, interim dispatch center director Kathy Krusiec said it was possible that confusion was "created by an abandoned land line 911 call that came in right after the wireless 911 call."

Operations environment

Operations Manager Rich McVicar concluded the cause of the operator not hearing the scream may have been "an environment where multiple things are happening."

Robert Kaelin, a Seattle-based consultant who wrote the 911 center's 2004 strategic plan said that line from the report caused him the most concern.

"This means the 911 center may not be maintaining an environment where staff can focus and answer calls," Kaelin said. "This was an issue in our 2004 report."

The center is in the process of replacing furniture, consoles and other features of the center that negatively impact the acoustics.

In early November, another error committed by a new operator resulted in police not being dispatched to an escalating argument at Lake Edge Park on Madison's East Side. Mark Johnson was found severely beaten 90 minutes afterward and later died.

Kaelin couldn't say whether the Zimmermann and Lake Edge Park incidents were examples of the "catastrophic event" he predicted in his report if changes weren't made at the center.

"My crystal ball isn't that clear," Kaelin said.

Recommended changes

The county did not follow Kaelin's recommendations on staffing levels, replacement of the computer-aided dispatch system, division of labor, consolidation with other centers and quality assurance review of police calls.

The computer system, for example, which Gahagan criticized as being 20 years old, was recommended to be replaced by January 2009. The county included $2 million in next year's budget to start work on the project.

The county spent $40,000 in 2007 to upgrade the computer server, but Kaelin noted that recommendation was a patch intended to extend the 20-year-old system's lifespan to early 2009.

The new telephone system, which Gahagan also criticized, was added in 2006 for $492,000. Center officials acknowledged after the Zimmermann incident that they weren't using the phone system to track call volumes and response times to adjust staffing, as Kaelin recommended.

The county points to a new $30 million radio system now in the works and also Priority Fire Dispatch software added in 2007 and Priority Police Dispatch software being added in 2009 as examples of going above and beyond Kaelin's recommendations. The software programs standardize the questions operators ask callers.

Kaelin said dispatch software is "never the solution people think it is."

"The best solution is an experienced dispatcher with the radio capabilities, the dispatch system, experience with the geography and experience with the units they're supervising," Kaelin said.

Staffing needs

Kaelin said many of those changes required having the staff in place to oversee them. That's why he recommended adding eight positions in 2005 and more positions once call volumes were analyzed.

The county added six positions before the Zimmermann incident, including a support services manager, a supervisor and communicator in 2005, a database coordinator in 2006 and two communicators in 2008. The center has added 11 positions since May, including nine in next year's budget following the recommendations of a new consultant who criticized excessive overtime that was hurting morale and causing high turnover. A final report is expected in January.

Another problem Kaelin noted was the way the center handled relating the Zimmermann call to the public.

The county didn't alert the public of the errors or their conclusions until after it was revealed in the weekly newspaper Isthmus on May 1. Then-director Joe Norwick held a news conference that day but made misleading statements about the operator's actions.

William Gaut, a Florida-based public safety consultant who provided paid expert testimony in the court case for the media organizations, said it was unclear whether there was a "covert reason" for withholding the existence of the call. County officials say it was withheld because police asked that the time and content of the call be kept secret so as not to jeopardize the homicide investigation.

Gaut said officials shouldn't have withheld the existence of the call.

"Where there is evidence of a catastrophic failure of 911 emergency response, it is in the best interest of the public to be informed, where such information may be used by the public political process to reduce or eliminate such future failures," Gaut testified.

The response of public officials to mistakes at the 911 center was "clumsy at best," Dane County Circuit Court Judge Richard Niess said last week, though he ruled against releasing the audio.

Niess released several other documents, including the full internal investigation and the e-mail from Gahagan.

Disclosure advocated

Media attorney April Barker argued during last week's court hearing that the media lawsuit, filed May 13, was critical in bringing much of the information about problems at the center to light.

"We didn't know the operator's side of the story until e-mails revealed she tried to raise equipment concerns," Barker said. "Meanwhile, other 911 mistakes continue to happen."

"You can't know whether the fix was appropriate until you know how serious the mistake was," Barker said.