This is Not A Drill, Part II

So I’ve been fascinated by the false alarm missile attack that occurred earlier this month in Hawaii. Today’s Washington Post peels back more of that onion, leading to some pretty interesting stuff.

Per the Post, sending the missile alert was not a mistake brought on by a poorly designed user interface or any other factor – but a deliberate act by a person who sincerely believed missiles were inbound.

Per the Post:

The emergency worker who sent a false public safety alert on Jan. 13 warning of an imminent  ballistic missile attack on Hawaii believed that a ballistic missile was truly bound for the state after mishearing a recorded message as part of an unscheduled drill, according to a preliminary investigation by federal officials.

The Post notes that while the recorded message began with the phrase “Exercise, exercise, exercise” (mimicking the “this is a drill” I’m familiar with in my experience in emergency response) it concluded with the phrase “This is not a drill.”

(That’s what the Post says. The Honolulu Star-Advertiser says the message concluded with “Exercise, exercise, exercise” after the “this is not a drill” statement.)

The worker who sent the notification missed the “exercise, exercise, exercise” portions of the recording, and the rest is, as they say, history – mostly a history of soiling drawers throughout the state of Hawaii for 38 minutes before a false alarm announcement was sent out.

Oopsie.

There are other error precursors too:

The drill took place at a shift change, when peoples’ heads weren’t yet “in the game.”

The supervisor of the shift coming on duty was aware of an imminent drill, but thought it was directed at the shift coming off-duty, so he or she was mentally unprepared for the exercise when it started.

The computer system that sends the notification was programmed to ask the sender to confirm actions – but used the same wording for an actual emergency as it would for a drill (not that this would have mattered at this point, as the sender’s mindset was ACTUAL EMERGENCY).

There was no contingency plan in place to correct a false alert, thus a plan had to be drafted while the alert was live – adding time to the debacle.

Only one person had to be present to send messages and alerts – a mistake the state has corrected.

Pile up enough precursors, and the chance for a mistake like this being made go up quickly.

What’s unclear in the media reports is if this action was done in a vacuum – without the presence of others on the emergency response team – or if the action was taken in a group setting (as all of our drills or actual emergency responses take place). Had this been in a team environment, there might have been enough ancillary clues around for the worker who missed the “exercise” portion of the drill to be keyed in on the fact this was a drill, not an actual emergency.

And if there weren’t any immediate clues, someone in a team environment could simply ask “is this a drill?” and get confirmation from others who may have heard (or listened) to the full message that the vent was a drill, or real, or whatever.

Reading the report, though, it’s clear this alert went out in a team environment where others in the room understood the event was a drill, while the one person sending the alert missed that part of the story (link opens a PDF).

Leaving any responder to make a decision like this when there’s no one else to turn to for confirmation is a true Hobson’s Choice, and not good emergency management, even to an amateur like me. However, sending out an alert without asking your co-workers for confirmation is, well, stupid. Even Stormtroopers know that.

Disclaimer: I am a moron. I am not speaking on behalf of my employer or place of work. Anyone who thinks otherwise is selling something.