Anatomy of an Event: What really happened in Hawaii?

On January 13, 2018, the Hawaii Emergency Management Agency sent out the following alert to cell-phones across the islands: “BALLISTIC MISSILE THREAT INBOUND TO HAWAII. SEEK IMMEDIATE SHELTER. THIS IS NOT A DRILL.” Fortunately, it WAS a drill, but the people of Hawaii didn’t find out for 38 minutes; the time it took to revoke the alert. For 38 minutes an entire US state was thrust into panic.

It didn’t take long for the headlines and talking-heads to start the familiar refrain of “human error.” It was plastered on front-pages, web pages, social media feeds, and led the evening news. Human error. Worker fault. Simple mistake. It was a quick and tidy answer that allows us to easily compartmentalize the event and move on with our lives. “Someone messed up. Glad I’m not that person. Oooo a cat video!”

However, if you are familiar with human error, (and if you’re reading this you probably are) you likely heard the news's answer and thought “Wait for it…”. You knew there was more to the story than human error. You knew, once more details emerged, that the organization’s poor management and lack of error defenses were going to be exposed. Well, “more details” are here; try not to look too smug.

The initial investigations are starting to be released and, as expected, it wasn’t just human error. Let’s look at the anatomy of this error by looking at the REMEDY formula that should have been in place all along. (Read this blog if you need a quick reminder about human performance 101 and Knowledge Vine’s REMEDY formula.)

RE- Reduce Error: This is the active error by the individual worker. In this case, it was the emergency management employee falsely thinking there was an actual attack and issuing the warning. The initial coverage led us to believe he just “clicked” the wrong button, but now we are learning he intended to send the alert. The error wasn’t in button pushing; it was an error in judgement. But how did he think it was an actual attack? Because of another active error.

It appears the supervisor announcing the drill gave conflicting information. He announced “Exercise, exercise, exercise” before and after his message. However, the body of the notification was taken from an actual message which included the phrase “this is not a drill.” This part of the communication likely piqued the ears of the employee who then immediately initiated the alert.

M- Manage: Did ineffective management allow incorrect behaviors to continue? Yep. The report found that the employee had been a “source of concern” for 10 years. According to an AP report on the investigation “Hawaii emergency management officials knew for years that an employee had problems performing his job... The worker had mistakenly believed drills for tsunami and fire warnings were actual events, and colleagues were not comfortable working with him, the state said Tuesday. His supervisors counseled him but kept him for a decade in a position that had to be renewed each year.”

ED- Error Defense: Again, per investigators, the agency did not require an alert to be second checked before it is sent; as many agencies do. Additionally, they found that the checklist for missile alerts was vague and allowed workers to interpret the steps they should take. The impact of these organizational errors were compounded by the long delay in retracting the alert because the agency did not have a process in place to do it. These are all latent errors that could have been addressed at any time over the years. 

Y- Yield: Did they anticipate results and design outcomes to get the results they wanted? It certainly doesn’t look that way. They saw the deficiencies in their worker behaviors and organizational defenses but failed to address them.

Looking at all the elements of REMEDY, would you still call this simply “human error”? Was this event predictable, preventable, and manageable?  Did Hawaii Emergency Management have an opportunity to be proactive rather than reactive? Are cat videos the best?