Outside review finds systemic shortcomings in Wichita response to Brook Hollow apartment fire

Jensen Hughes presented the results of its post‑incident analysis of the Oct. 13, 2023 Brook Hollow Apartments fire to the Wichita City Council, saying the fatality of resident Paoli Badeschi resulted from a combination of system shortcomings rather than a single, identifiable failure.

The consultant said its team reviewed policies, SOPs, building permits and drawings, conducted two site visits and interviewed personnel from the Wichita Fire Department (WFD), Sedgwick County Emergency Communications (SCEC), Sedgwick County EMS and the Wichita Police Department (WPD). Jensen Hughes noted the building (8165 East Central) was constructed in the late 1970s to then‑applicable codes and lacked a required sprinkler system only under current, later standards.

The firm highlighted three technical and operational areas of concern. First, Sedgwick County Emergency Communications did not understand or relay the unit number Ms. Badeschi provided on her 911 call; the report says the call taker did not use an available instant‑recall playback feature that might have clarified the unit number. Consultant Brian Nelson described differences between the carrier audio and what dispatchers hear on their console and said SCEC was operating on minimum staffing at the time, which may have increased cognitive load.

Second, Jensen Hughes identified a delay in dispatching a requested second alarm tied to a workflow/CAD (computer‑aided dispatch) issue; Nelson said multiple dispatchers and a supervisor were unable to perform the CAD steps to issue the second alarm and that administration provided retraining within days.

Third, Vernon Champlin reviewed WFD fireground operations and concluded that, while response times and the assembly of an effective responder force met NFPA benchmarks, several tactical and command failures hindered search efforts. Among the findings: handlines were flowed from Engine 15’s tank before a continuous water supply was established; some companies searched uninvolved buildings while the primary structure (Building 300) remained incompletely searched; command was not formally established until the seventh arriving unit; a Rapid Intervention Crew (RIC) was not formally in place during interior operations; and radio benchmarks were not broadcast per the department’s operations manual. Rescue personnel transmitted a Mayday after a partial stairway collapse; the firm said Mayday procedures were not followed consistently and recommended complex multi‑company Mayday training.

Jensen Hughes also criticized some aspects of the local Fire Investigations Unit’s practices, saying documentation provided to the consultants lacked systematic scene photography, control samples for evidence testing and complete origin‑and‑cause reporting; consultants reported the origin had been located in the exterior stairwell area near Units 303–304 but that the cause remained under investigation.

The report acknowledged external, non‑operational factors that likely affected the outcome — notably wind conditions the morning of the fire, combustible conditions at the exterior stairwell and evidence of discarded smoking materials by the stair — and said those elements, combined with operational shortcomings, reduced the likelihood of an early rescue.

City officials and WFD leaders responded during Q&A that some steps already had been taken. The WFD chief described a new officer development program, a monthly randomized training regimen and increased joint meetings with county partners. Council members pressed consultants and county staff for specifics on why instant recall was not used and whether dual headsets used by dispatchers contributed to confusion; Brian Nelson and a former dispatcher, Scott Rickenham, explained that playback is not used on every call but would typically be used when the taker cannot understand critical information and that dual headsets (separate phone and radio audio) can produce comprehension challenges.

The consultant recommended a combination of near‑term operational fixes (retraining on CAD procedures, adoption or enforcement of instant‑recall use where needed, clearer guidance on RIC and Mayday procedures), technology adjustments (reduce cognitive load at consoles, reconsider dual‑headset workflows and improve radio/console audio integration) and longer‑term cultural and organizational strategies (interagency benchmarking, accreditation, increased joint training and an emphasis on incident‑command discipline and humility). City staff said they plan to develop implementation strategies based on Jensen Hughes’ recommendations and to convene department heads for follow‑up.

The special council meeting concluded after a brief question period; a motion to adjourn passed 6–0.

Ending: City leaders said they will assemble implementation strategies for the council based on the report’s recommendations and pursue follow‑up meetings with county partners and the affected departments.