'Human error' caused false Pickering, Ont. nuclear alert, investigation reveals
QUEEN'S PARK -- The false emergency alert that triggered a province-wide wave of panic about an incident at the Pickering Nuclear Generating Station was due to “human error,” according to an Ontario government-led investigation that also revealed a breakdown in communication and lack of training exacerbated the problem.
The emergency alert, that shook many out of bed in the early hours of Sunday, Jan. 12, was accidentally sent out by a duty officer at the Provincial Emergency Operations Centre as they were starting their shift.
According to the report, officers routinely log into the live Alert Ready system to ensure access, before logging out and switching to the test system to perform a daily test using a “pre-scripted nuclear template for the Pickering Nuclear Generating Station.”
While the officer immediately “recognized the error” the investigation found that from the moment the initial alert was issued at 7:23 a.m. until the correction was issued 108 minutes later, there was a behind-the-scenes scramble to determine the exact procedure for retraction of the alert.
“Despite a series of consultations with on-duty, on-call and off-duty Emergency Management Ontario supervisors at different levels, no clear instructions were provided to the on-duty (officers) in the immediate aftermath of the first alert,” the report reads
At the same time Pelmorex, the company that operates the alert system, raised issues about “alert fatigue” if a second message was issued, “consistently advised against” sending a second alert and suggested issuing a correction on Twitter instead.
Only after a flurry of emails and text messages between senior government official, the Solicitor General’s office, Emergency Management Ontario, and the Provincials Emergency Operations Centre were sent, was the decision made to send another emergency alert correcting the mistake.
At 9:11 a.m. the same employee who sent the first alert issued the correction “under the supervision of employees and supervisors in the (operations center)” telling Ontario residents that there was no danger to the public and no action was required.
The investigation into the misfire, triggered by the Ontario government, found several issues with the Alert Ready system, including allowing multiple users to access the training and live systems “simultaneously on any device.” Officers also had the ability to draft and send alerts “without managerial approval.”
The report found that while “human error” was to blame for the initial alert, “procedural gaps, lack of training, lack of familiarity with the Alert Ready system and communication failures” also contributed to the confusion.
The Provincial Emergency Operations Centre says all duty officers have completed “refresher training” while new procedures are now in place to ensure that an “end alert” can be sent in the case of an error.
Solicitor General Sylvia Jones said in a statement she is “confident” that the gaps in the system have been addressed, to make the alert management system “even stronger.”