Case study: Hawaii False Alarm Creates Panic for 38 Minutes - Work Process Improvement Opportunity

Holly Maher

 Digging into the work process

You may have seen the news stories that reported that on Saturday, January 13th, a false emergency missile alert was sent out to residents and vacationers in Hawaii. Not only was the false alert sent out, but it was 38 minutes before a recall was sent to correct the original misinformation. I can only imagine the panic and stress those individuals must have endured during those 38 minutes. But with all negative events, even those with the most significant of consequences, there is always something we can learn from this “unfortunate” incident that happened; there is a work process improvement in there somewhere.

If we were using this incident as a case study for Cause Mapping, we would start by identifying the goals impacted by this issue. If you view the residents and vacationers as customers of the Emergency Management Agency, then clearly the customer service goal was impacted due to the 38 minutes of panic, stress, loss of productivity, impact to personal schedules, etc. These were a result of not only the initial false alert being sent out, but also that it took 38 minutes to retract the false alert. Both causes prompt additional why questions. Why was the false alert sent out? Why did it take 38 minutes to retract the false alert?

Are the steps effective?

The false alert was sent out during a routine drill, which is intended to test Hawaii’s nuclear warning siren system. The monthly testing had only been recently initiated in December, in response to recent tensions with North Korea. During the drill, an officer in the emergency operation center selected a template that would send the alert to the public vs. selecting a template that would send the alert internally. In addition, there was a step in the system that prompted the officer to confirm he did want to select this template, and the officer selected “yes”. At the time, there was no secondary, independent “check” to confirm the template selected.

It took 38 minutes for the emergency operation center to send out a retraction alert because there was no template built for a false alarm alert.  

What was missed before implementation?

Some additional questions that come to mind: How was the new drill work process rolled out? What training was provided on the drill work process? Why was there no false alarm template created? When the second confirmation prompt pops up for the operator to check “yes” – what does it ask? Does it give any warning? Is there any confusion on labeling of templates? These additional questions and causes might reveal additional possible solutions.

In this video lead investigator and CEO, Mark Galley identifies work-process improvements that can be used to avoid terrifying an entire state. *Cause Map created by instructor, Holly Maher.
Want the Cause Map of Hawaii's false missile alert? DOWNLOAD HERE.

So, in the spirit of Monday morning quarterbacking, knowing what we know now, what would we do differently? (By the way, if anyone ever says that during an investigation, you can confirm that that is exactly what we are doing. We are reviewing the tapes the day after the game, so we can learn from whatever didn’t go well. That is exactly what incident investigations are about.) News reports indicate the Emergency Management Agency has implemented a second, independent check before an alert can be sent out. In addition, they have created a false alarm alert template that would allow them to correct misinformation more quickly in the future.   Both of these solutions are changes to the emergency missile alert process, steps that mitigate the risk for a similar event in the future.

What other work processes are at risk?

If we really want to leverage as much benefit as we can from a negative event, the next step is to see if any other systems have the same risk? For example, Hawaii is susceptible to tsunamis. What are the steps of the emergency tsunami alert process and is there a potential for a false alarm? And if we send out a false tsunami alarm, is there a template to retract that false alarm in a timely manner? What about the emergency alert processes in other states? Do they have similar gaps and vulnerabilities? Should there be a federal standard emergency alert process that contain some of these lessons learned? Do we really have to wait to have a similar incident somewhere else before we apply the same learnings?

Root cause analysis cause mapping Public Workshop


Share This Post With A Friend


Similar Posts

Facilitate Better Investigations | Attend a Webinar