OPENPUBLICA · PUBLIC MEETING RECORD
Record of Proceedings

Wichita City Council Special Meeting on Brookhollow Fire Analysis - December 16, 2024

City CouncilMonday, December 16, 2024
BodyWichita, Kansas
SessionCity Council
DateMonday, December 16, 2024
StatusFILED
Video Record

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Transcript — Verbatim
20:03

I'm gonna call this special meeting to order on December 16th.

20:08

Madam Clerk, please call the first item.

20:12

Jensen Hughes post-incident analysis of Broccolo fire incident.

20:23

Thank you very much for having us here today.

20:26

Today we're gonna present our post-incident analysis report about the Brookhollow apartment fire.

20:31

Today with me, I have a couple of the uh uh members of the team.

20:36

Uh first uh Vernon Champlin.

20:41

I have uh Brian Brian Nelson right here, and uh Scott Rickenham.

20:47

Uh those are were four of the total of nine of us that worked on this uh this analysis.

20:57

All right, so today I'm gonna run you through um just a high level of our approach uh uh and our assignment and approach to this uh PIA.

21:07

Um we're gonna give a little bit of the report outline which you have.

21:10

Um we're gonna review the incident and we're gonna review the incident analysis and recommendations agency by agency.

21:16

We're gonna talk a little bit about key findings and then talk about how we move forward as a public safety system.

21:24

So, first of all, why are we here?

21:25

We're here because of the Brookhall apartment fire, which occurred on October 13th, 2023.

21:31

That tragically took the life of Ms.

21:32

Paoli Badeschi, but it also injured several other occupants and could have harmed many others, including first responders.

21:40

So our assignment was a thorough evaluation of the public safety system uh uh that responded to this fire uh to understand first of all their policies and procedures and uh those meeting exceeding and how do they compare with uh other jurisdictions, as well as looking specifically at the uh these agencies, uh how they performed on this incident and how their actions may have affected the incident outcome.

22:09

And finally, our task was to identify a strategy to and create a plan to improve the outcomes of the public safety system as a whole uh to restore public trust and confidence.

22:27

Our report that you have uh identifies overarching themes and gaps in administrative operational processes, as well as where the agencies and uh policies and procedures are considered adequate as well.

22:39

Right.

22:39

So this is not just pointing out where it doesn't work, but where it is uh where it does work.

22:44

For for all the agencies involved, we analyzed a number of documents here uh on the left-hand side of the screen, um, policies and procedures, organizational frameworks, um of again all the public agencies involved, which were the Wichita Fire Department, the Wichita Police Department, uh, Cedric County Emergency Communications, as well as Sedgwick County uh EMS.

23:08

Uh we went uh uh we went and also looked uh uh at the building code and looking at the was the building constructed it correctly at the time of construction.

23:18

Um we also looked at actions that were taken uh before uh the incident as well uh that may have impacted the incident itself.

23:27

We conducted two site visits and a number of follow-up interviews and phone calls uh with all of the agencies and all the entities you see here on the right-hand side of the screen.

23:40

There's of course limitations to any analysis.

23:42

Um we relied on the available information and data that we were provided.

23:47

Um we stand behind the findings that we present to you in this report.

23:52

Um we believe we collected them with discretion, investigative diligence, and professional respect.

23:58

Our findings, of course, are subject to change if additional relevant and factual information is provided.

24:04

I will say that through the assistance of Dante Martin and Rusty Leeds at the county and Dante Martin here at the city.

24:15

Uh they were our liaisons to this, and anything we asked for, they got us access to.

24:21

Um if we weren't given the information, we were um told why it didn't exist, essentially.

24:28

So we don't expect uh additional information.

24:31

Um the report structure itself uh goes into the background of all the agencies uh just for record.

24:42

Um it then goes and talks about the incident overview itself.

24:46

Um we then, like I mentioned, go through in the report uh agency by agency, uh, the analysis of the actions that they took, talks we look and review their SOGs and SOPs, um, and we find recommendations for each agency to improve.

25:03

Finally, the moving forward section is our conclusions.

25:07

It provides a path forward for this public safety system to improve its response to citizens of Wichita as well as the county itself.

25:20

And then there's a number of appendices at the back of the report.

25:27

All right, we're gonna get into the incident next, but first we want to remind as we talk about this in detail.

25:34

We want to remind everyone about what is the Brookalo Apartment Complex, how is it laid out?

25:39

That will play into some of the challenges that uh all the public safety agencies found when they're responding to this fire.

25:46

So the Brookhallo apartment complex was at 8165 B Central.

25:50

It has a single vehicle entry and exit in the north uh east corner to the complex.

25:58

The complex itself, the apartment building itself is comprised of 12 two-story buildings.

26:03

They're garden style apartments, so two above grade and one half below grade being the garden apartment.

26:09

And there's approximately 72 units in the complex.

26:12

Each building has a single exit stair to a common weather protected but open stairwell.

26:19

I will point before moving on from this slide that there is a wood fence that surrounds the entire north, west, and south of this property.

26:28

The only opening in the fence uh uh is to the northwest, where there's a person size opening uh to allow people to go to the north.

26:40

But other than that, the only vehicle access in and out of this complex is to the northeast.

26:46

On the evening or on the morning of October 13, 2023, there was a very strong wind coming out of the uh west northwest.

26:54

Uh we're gonna focus here on building 300 because that's uh where the fire occurred, which is in the northwest corner of the apartment complex.

27:07

All right, so building 300 uh is comprised of six units, about 580 square feet each.

27:12

Uh, they're all single bedroom units in this building.

27:15

Two per floor, like we mentioned.

27:17

Every unit is provided with an ABC dry chemical fire extinguisher by the property management, as well as a smoke, a working smoke alarm.

27:25

Uh the fire alarm, there is no fire alarm system, there was no fire alarm system at the building, like automatic fire alarm system at the building at the time of the fire, and there is uh there was not one required.

Discussion Breakdown — Share of Meeting
Public Safety█████████████████████████████████████████████65%
Fire Safety███████10%
Technology and Innovation██████8%
Procedural███4%
Workforce Development███4%
Emergency Medical Services██3%
Public Works2%
Emergency Management2%
Public Engagement2%
Summary of Proceedings

Wichita City Council Special Meeting on Brookhollow Fire Analysis - December 16, 2024

On December 16, 2024, at 12:00 PM, the Wichita City Council held a special meeting in the Council Chambers, 455 N. Main Street, to receive the Jensen Hughes Post-Incident Analysis (PIA) of the Brookhollow Apartment Fire that occurred on October 13, 2023, resulting in the death of resident Paoli Bedeski, injuries to other occupants, and a firefighter Mayday event. The presentation, led by Jensen Hughes representatives John, Vernon Champlin, Brian Nelson, and Scott Rickenham, covered the incident timeline, agency-by-agency analysis, key findings, and recommendations for the Wichita Fire Department (WFD), Sedgwick County Emergency Communications (SCEC), Sedgwick County EMS, and Wichita Police Department (WPD). No public comments were received.

Discussion Items

  • Incident Overview: The fire occurred at the Brookhollow Apartment Complex (8165 W. Central), a 12-building, 72-unit garden-style complex constructed in 1977. Building 300, where the fire started, had six units. Ms. Bedeski called 911 at 3:58 AM, stating her apartment was on fire (unit 306). She stopped speaking 48 seconds later. The WFD was dispatched at 3:59 AM. First units arrived at 4:03 AM, reporting heavy fire from the second floor. A second alarm was requested at 4:15 AM but not dispatched until 4:20 AM due to a CAD issue. The stairway roof partially collapsed at 4:13 AM, triggering a Mayday. Ms. Bedeski was found unresponsive in her bathroom by Rescue 2 at approximately 4:21-4:24 AM, extricated by 4:26 AM, and transported to the hospital at 4:54 AM, arriving at 5:02 AM. She later died.
  • Jensen Hughes Findings: No single point of failure was identified. Instead, multiple systematic shortcomings contributed to an unorganized rescue effort. Key issues included:
    • SCEC dispatcher could not understand Ms. Bedeski stating her unit number (306) and did not use the available instant recall feature to replay the audio.
    • SCEC delayed dispatching the second alarm by several minutes.
    • WFD failed to establish incident command until the seventh unit arrived (Battalion 3 at 4:05:21 AM), leading to freelancing and uncoordinated search. Units searched uninvolved buildings (200, 400, 1100, 1200) before completing the primary search of Building 300.
    • Water supply delays: first engine did not lay a supply line; a hydrant was blocked by a truck; crews advanced without water.
    • The Mayday handling was not per WFD Operations Manual: no IRIC/RIC, no alarm upgrade, no channel management, and the incident was switched to defensive, pausing search and rescue.
    • No Vent-Enter-Search (VES) was performed near the fire.
    • WFD Fire Investigation Unit left the scene 45 minutes before the last fire unit cleared; scene documentation was incomplete.
    • EMS was not automatically dispatched to structure fires without a report of trapped persons, delaying their response. Triage area was not established or communicated.
    • WPD was not automatically dispatched but could assist with size-up, traffic control, and occupant alerting.
  • Recommendations: Improve SCEC technology (integrate headsets, train on instant recall); reconsider dispatch protocols for EMS on high-life-hazard fires; develop WPD-WFD policies for police assistance; conduct multi-company Mayday training; enhance command and control; adopt benchmarking and accreditation via the Center for Public Safety Excellence; address fire department culture to reduce siloed, independent actions and foster humility and collaboration.
  • Council Q&A: Councilmembers asked about the word "trapped" vs. "help," the dual-headset issue, Mayday training, and culture. Chief Snow noted that since the incident, WFD has initiated officer development training, monthly skills assessments, and weekly collaboration meetings with county partners. Vice Mayor Ballard and Councilmember Tuttle pressed for specifics on training and culture.

Key Outcomes

  • No formal vote on the report; the meeting concluded with a motion to adjourn, which passed 6-0.
  • City Manager Leighton stated that the city will formulate implementation strategies at two levels: fire department-specific recommendations and interagency coordination with Sedgwick County.
  • Jensen Hughes urged the public safety system to move past grievances, rebuild trust, and seek external benchmarking.
  • The council accepted the report for further review and action.

Meeting Transcript

I'm gonna call this special meeting to order on December 16th. Madam Clerk, please call the first item. Jensen Hughes post-incident analysis of Broccolo fire incident. Thank you very much for having us here today. Today we're gonna present our post-incident analysis report about the Brookhollow apartment fire. Today with me, I have a couple of the uh uh members of the team. Uh first uh Vernon Champlin. I have uh Brian Brian Nelson right here, and uh Scott Rickenham. Uh those are were four of the total of nine of us that worked on this uh this analysis. All right, so today I'm gonna run you through um just a high level of our approach uh uh and our assignment and approach to this uh PIA. Um we're gonna give a little bit of the report outline which you have. Um we're gonna review the incident and we're gonna review the incident analysis and recommendations agency by agency. We're gonna talk a little bit about key findings and then talk about how we move forward as a public safety system. So, first of all, why are we here? We're here because of the Brookhall apartment fire, which occurred on October 13th, 2023. That tragically took the life of Ms. Paoli Badeschi, but it also injured several other occupants and could have harmed many others, including first responders. So our assignment was a thorough evaluation of the public safety system uh uh that responded to this fire uh to understand first of all their policies and procedures and uh those meeting exceeding and how do they compare with uh other jurisdictions, as well as looking specifically at the uh these agencies, uh how they performed on this incident and how their actions may have affected the incident outcome. And finally, our task was to identify a strategy to and create a plan to improve the outcomes of the public safety system as a whole uh to restore public trust and confidence. Our report that you have uh identifies overarching themes and gaps in administrative operational processes, as well as where the agencies and uh policies and procedures are considered adequate as well. Right. So this is not just pointing out where it doesn't work, but where it is uh where it does work. For for all the agencies involved, we analyzed a number of documents here uh on the left-hand side of the screen, um, policies and procedures, organizational frameworks, um of again all the public agencies involved, which were the Wichita Fire Department, the Wichita Police Department, uh, Cedric County Emergency Communications, as well as Sedgwick County uh EMS. Uh we went uh uh we went and also looked uh uh at the building code and looking at the was the building constructed it correctly at the time of construction. Um we also looked at actions that were taken uh before uh the incident as well uh that may have impacted the incident itself. We conducted two site visits and a number of follow-up interviews and phone calls uh with all of the agencies and all the entities you see here on the right-hand side of the screen. There's of course limitations to any analysis. Um we relied on the available information and data that we were provided. Um we stand behind the findings that we present to you in this report. Um we believe we collected them with discretion, investigative diligence, and professional respect. Our findings, of course, are subject to change if additional relevant and factual information is provided. I will say that through the assistance of Dante Martin and Rusty Leeds at the county and Dante Martin here at the city. Uh they were our liaisons to this, and anything we asked for, they got us access to. Um if we weren't given the information, we were um told why it didn't exist, essentially. So we don't expect uh additional information. Um the report structure itself uh goes into the background of all the agencies uh just for record. Um it then goes and talks about the incident overview itself. Um we then, like I mentioned, go through in the report uh agency by agency, uh, the analysis of the actions that they took, talks we look and review their SOGs and SOPs, um, and we find recommendations for each agency to improve. Finally, the moving forward section is our conclusions. It provides a path forward for this public safety system to improve its response to citizens of Wichita as well as the county itself. And then there's a number of appendices at the back of the report. All right, we're gonna get into the incident next, but first we want to remind as we talk about this in detail. We want to remind everyone about what is the Brookalo Apartment Complex, how is it laid out? That will play into some of the challenges that uh all the public safety agencies found when they're responding to this fire. So the Brookhallo apartment complex was at 8165 B Central. It has a single vehicle entry and exit in the north uh east corner to the complex. The complex itself, the apartment building itself is comprised of 12 two-story buildings. They're garden style apartments, so two above grade and one half below grade being the garden apartment. And there's approximately 72 units in the complex. Each building has a single exit stair to a common weather protected but open stairwell.

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