A combination of human error and improper safeguards led the worker to deliberately send the alert message, which sowed widespread confusion and fear for 38 minutes, the Federal Communications Commission said in its report Tuesday.
The mistake began with a night-shift supervisor who decided to test incoming day-shift workers with a spontaneous drill. The supervisor managing the day-shift workers appeared to be aware of the upcoming test but believed it was aimed at the outgoing night-shift workers. Thus the day-shift manager was not prepared to supervise the morning test, the FCC said.
As a result, there was a lack of supervision when the night-shift supervisor called the day-shift workers pretending to be the U.S. military's Pacific Command, which is charged with detecting missile threats.
Following standard procedures, the night-shift supervisor posing as Pacific Command played a recorded message to the emergency workers warning them of the fake threat. The message included the phrase "Exercise, exercise, exercise." But the message inaccurately included the phrase "This is not a drill."
The worker who then sent the emergency alert failed to hear the "exercise" portion of the message and acted upon the "This is not a drill" part of the message that should not have been included, according to the report.
The mistake was not stopped by the Hawaii emergency management agency's computer systems because there is little difference between the user interface for submitting test alerts and the one for sending actual alerts.
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