Full Text: State of Hawaii report on false missile alarm

Report can also be found here.

TO:                   Major General Arthur J. Logan

Director of Emergency Management (HI-EMA)

FROM:            Brigadier General [Ret] Bruce E. Oliveira

Investigating Officer

DATE:             January 29,2018

SUBJECT:              FALSE BALLISTIC MISSILE ALERT INVESTIGATION FOR JANUARY 13, 2018

ASSIGNMENT:

On January 15, 2018, Major General Arthur J. Logan, the Director of HI-EMA for the State of Hawaii, assigned me to investigate this incident to determine by a preponderance of the evidence the following:

a. What was the exact chain of events that led to the issuance of a state­ wide ballistic missile alert (BMA) message, initiated during the course of the HI­ EMA State Warning Point (SWP) change of shift at approximately 0805 hours on January 13, 2018?

b. What was the established protocol that HI-EMA SWP members were to follow during the change of shift BMA Checklist simulation and who established the BMA checklist?

c. How many times had HI-EMA SWP members previously practiced the BMA checklist that led to the issuance of the false alert message, and what, if any, training records exist?

d. Did the established BMA checklist during the simulated test include a response protocol in the event a false state-wide BMA message was issued, and if so, did HI-EMA SWP members follow BMA response protocol on January 13,

2018?

SYNOPSIS:

At approximately 8:06 am, the SWP mistakenly issued a BMA.  As the investigating officer and carefully considering the facts, I find a preponderance of evidence exists that insufficient management controls, poor computer software design, and human factors contributed to the real-world BMA and the delayed false BMA correction message that was issued over the WEA/EAS on January

13,2018.

DATE/TIME OF OCCURRENCE:

January 13, 2018

LOCATION OCCURRED:

The incident occurred at the State Warning Point of the Hawaii Emergency Management  Agency located within the State Emergency Operating Center in Diamond Head.

Full report -- FCC preliminary findings on Hawaii false missile alert

FULL report: FCC preliminary findings.

Preliminary Report:

Hawaii Emergency Management Agency’s
January 13, 2018
False Ballistic Missile Alert

January 30, 2018

•    At 8:07 AM on January 13, 2018, the Hawaii Emergency Management Agency (HI-EMA) issued a false ballistic missile alert through the Emergency Alert System (EAS) and Wireless Emergency Alert (WEA) System.    Chairman Pai immediately called on the Bureau to investigate.

•    To date, the Bureau has interviewed key stakeholders, including:
–    HI-EMA employees
–    Representatives of other emergency management agencies across the country
–    Alert origination software vendors (including the vendor who supplies HI-EMA)
–    Wireless service providers

•    The Bureau’s investigation is ongoing.

2

Events Leading Up to the False Alert

Time    Events

0805    •    HI-EMA’s midnight shift supervisor begins a no-notice ballistic missile defense drill at
a shift change by placing a call, pretending to be U.S. Pacific Command, to the day shift warning officers.

•    The midnight shift supervisor plays a recording over the phone that properly includes the drill language “EXERCISE, EXERCISE, EXERCISE,” but also erroneously contains the text of an EAS message for a live ballistic missile alert, including the language, “THIS IS NOT A DRILL.” The recording does not follow the script contained in HI-EMA’s standard operating procedure for this drill.

•    The day shift warning officers receive this recorded message on speakerphone.

•    While other warning officers understand that this is a drill, the warning officer at the alert origination terminal claimed to believe, in a written statement provided to HI- EMA, that this was a real emergency, not a drill.

0807    •    This day shift warning officer responds, as trained for a real event, by transmitting a
live incoming ballistic missile alert to the State of Hawaii.

•    In doing so, the day shift warning officer selects the template for a live alert from a drop-down menu, and clicks “yes” in response to a prompt that reads, “Are you sure that you want to send this Alert?”

Events After the False Alert

Time    Events
0808    •    Day shift warning officer receives false WEA on mobile device
0809    •    HI-EMA notifies Hawaii Governor of false alert
0810    •    HI-EMA to U.S. Pacific Command and Honolulu PD: no missile launch
0812    •    HI-EMA issues a cancellation, ceasing retransmission over EAS, WEA
0813    •    HI-EMA begins outreach, but its phone lines become congested
0820    •    HI-EMA posts on Facebook, Twitter – “NO missile threat to Hawaii”
0824    •    Hawaii Governor retweets notice that there is no missile threat
0827    •    HI-EMA determines that an EAS, WEA Civil Emergency Message (CEM) is the best vehicle for correction
0830    •    FEMA confirms HI-EMA’s view on CEM; Hawaii Governor posts correction on
Facebook
0831    •    HI-EMA supervisor logs into alert system, begins to create false alert correction
0845    •    HI-EMA issues correction through EAS and WEA that there is no missile threat

1.    A combination of human error and inadequate safeguards contributed to the transmission of this false alert.

2.    HI-EMA’s lack of preparation for how to respond to the transmission of a false alert was largely responsible for the 38-minute delay in correcting the alert.

3.    HI-EMA has taken steps designed to ensure that an incident such as this never happens again.

•    The Bureau will continue its investigation and issue a final report, including recommended measures to safeguard against false alerts and to mitigate their harmful effects if they do occur.

•    After the issuance of the final report, the FCC will partner with FEMA to engage in stakeholder outreach and encourage the implementation of best practices.

•    Federal, state, and local officials must work together to prevent such a false alert from happening again.

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