NEW YORK (CBSNewYork) — A scathing report released Tuesday concluded that human error and a flawed dispatch system played a role in a fire that claimed the lives of two young children earlier this year in Queens.

Four-year-old Jai’Launi Tinglin and his 4-year-old half-sister, Aniya, were killed in the Easter morning fire that broke out at a home on Bay 30th Street in Far Rockaway.

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As WCBS 880’s Alex Silverman reported, neighbors at the time said firefighters were shouting “Where’s EMS?”

And indeed, as CBS 2 Political Marcia Kramer reported, it took an ambulance approximately 21 minutes to get to the scene after the initial 911 calls came – a time that city Department of Investigation Commissioner Mark Peters called “far too long.”

WEB EXTRA: Read The Full Report (pdf)

The report also found human error played a major role in the delay.

Peters said the probe found that the FDNY ambulance dispatch system is “unduly complicated” and “unacceptably flawed.”

“The way the dispatch system now works, it takes seven different people to engage in seven different steps to get an ambulance dispatched to the scene of a fire,” Peters said. “And we need a system in which several of those steps are eliminated.”

Peters said there were also human errors, including:

• Inadequate supervision;
• The mistaken belief by one dispatcher that another dispatcher notified EMS of the need to send an ambulance;
• The inability of the supervising dispatcher to use the computer competently.

“One of the people who was staffing one of the terminals thought a call had been made to the ambulance dispatch when it had not and then another person at another terminal incorrectly cleared away the emergency warning that basically said nobody’s yet called,” Peters told 1010 WINS.

The report further said the staff is poorly supervised and one dispatcher with a history of mistakes wasn’t reassigned or retrained.

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The findings of the report were no comfort to a family trying to rebuild.

“If the ambulance was here then, the children — they had smoke inhalation; they didn’t burn — they would not die,” said Estella Jackson Bernard, the children’s great grandmother and the owner of the home. “They would not die if the ambulance was here. I don’t know why the dispatcher didn’t dispatch the fire unit and dispatch the ambulance at the same time, and I’m very, very upset about that, because the children would be alive and not burn.”

Fire Commissioner Daniel Nigro, who took office after the fire, has already taken action to fix the system temporarily.

“Things did not go entirely right here,” Nigro said. “We’ve made changes. We’ve made changes in procedures. Right now, our fire dispatchers call EMS first to request an ambulance. We’re making technical changes. It’s really a sliver of our calls that this relates to.”

Peters said the FDNY has already put some initial stop-gap measures in place and will “pursue more advanced solutions.”

“They’re designing a series of technological computer bridges that we hope will be implemented within four to six months so that it will streamline the number of people who are involved in the process,” Peter said.

The investigation did not determine whether the children would have survived if the ambulances had arrived at the scene sooner, 1010 WINS’ Sonia Rincon reported.

“That’s something we don’t know; what we know is that there was an unacceptable delay in getting the ambulances to the fire and that the system needs changes,” Peters said.

The investigation did not find any criminal wrongdoing.

An FDNY spokesman said the two EMS dispatchers involved in the Far Rockaway fire response were suspended for 30 days, and retrained immediately after the fire. They could now face further disciplinary action.

Meanwhile, New York City has plans to redo the entire 911 system, but that fix might not happen for at least two years.

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