An investigation into what led to a false alarm being issued about a nuclear incident last month has concluded “human error” was the immediate cause, but “several systemic issues” contributed to the false alert and the delay in sending a cancellation.
The findings, which were released on Thursday, revealed that there were “procedural gaps, lack of training, lack of familiarity with the Alert Ready system and communication failures” which led to the false alert and the 108 minutes between the second alert.
Solicitor General Sylvia Jones tapped the chief of Emergency Management Ontario to conduct an investigation.
Watch: ‘Why is there no failsafe?’ Solicitor general questioned about nuclear alert sent in error
The alert about an incident at the Pickering Nuclear Generating Station was pushed to cellphones, radios and TVs across the province on the morning of Sunday, Jan. 12.
The emergency notification warned of an unspecified incident, but said there was no abnormal release of radioactivity and people near the facility didn’t need to take protective actions.
An all-clear alert was sent to cellphones nearly two hours after the original notification.
The investigation found that the alert had been sent when the duty officer believed he was logged into a training system, and not the Alert Ready live system used to send live alerts.
The report said that at the beginning of each shift change, the duty officer tests both the live and training systems. They are required to log in to the live system to ensure they have access and then log into the training system to practice issuing an alert.
On the day the alert was issued, the duty officer selected a pre-scripted nuclear template for the Pickering Nuclear Generating Station believing he was in the training system and accidentally sent a live alert. The report also detailed that the pre-scripted template in the training system does not have any distinctive labeling, such as “exercise.”
The report said staff immediately recognized the error and asked for guidance from his Emergency Management Ontario superiors.
As for the delay in issuing a correction, the report states after a series of consultations with supervisors at different levels, no clear instructions were provided to the duty officers. A timeline shows the deputy solicitor-general had been informed the alert was sent in error less than 20 minutes after it was sent.
“Supervisors were uncertain about whether or how to issue a second alert as broadcast intrusive, meaning that it would be broadcast in the same manner as the first alert,” the report said.
Pelemorex, which owns the Alert Ready system, had advised against issuing a second alert as it would undermine “public trust in the Alert Ready System.”
Eventually, senior Ontario Public Service executives were brought in to determine which corrective action to take.
The investigation found the duty officers working at the time of the false alert had their four-week training program cut short in November of 2019 in order to help coordinate the provincial response to emergency flood evacuation. Also, a review of the training system found the duty officers were not sending alerts on the training system at the beginning of their shifts as required.
Supervisors at Emergency Management Ontario also don’t have access to the Alert Ready system.
Technological gaps with the Alert Ready system were also found during the investigation including that a single user can draft and send an alert, and that the training and live systems can be open at the same time.
As a result of the investigation, the Provincial Emergency Management Operations Centre has taken corrective actions to address some of the concerns outlined.
Here are some of the immediate actions implemented:
- All messages used to test the Alert Ready system clearly indicate they are tests;
- The Alert Ready system verification process now requires two duty officers to conduct the test;
- Distinct login credentials are now used for the live and test platforms;
- All duty officers have received refresher training;
- A new procedure has been introduced to ensure an “end alert” message will be sent if an emergency alert is issued in error;
- All supervisors will undergo training on the Alert Ready system and will be granted access to it
The Ministry of the Solicitor General said they will also be conducting a review of staffing at the Emergency Operations Centre.
With files from The Canadian Press