The overnight-shift supervisor informed the day-shift supervisor of the plan but the day-shift supervisor understood the drill was for the overnight workers ending their shift not for his arriving staff.
"As a result, the day shift supervisor was not in the proper location to supervise the day shift warning officers when the ballistic missile defense drill was initiated," the FCC report said.
It said the overnight-shift supervisor called the day-shift warning officers at 8:05 am pretending to be from US Pacific Command.
A recorded message was played over the phone which began and ended with the words "exercise, exercise, exercise."
The message, however, also included the phrase "This is not a drill" used for an actual live ballistic missile alert, the report said.
Three day-shift warning officers listened to the recording on speakerphone and one of them "believed that the missile threat was real" and issued a live alert at 8:07 am after hearing the sentence "This is not a drill," it said.
The officer declined to be interviewed by the FCC but said in a written statement to HEMA that he did not hear the phrase "exercise, exercise, exercise."
"Other warning officers who heard the recording in the watch center report that they knew that the erroneous incoming message did not indicate a real missile threat, but was supposed to indicate the beginning of an exercise," the report said.
"Because we've not been able to interview the day shift warning officer who transmitted the false alert, we're not in a position to fully evaluate the credibility of their assertion that they believed there was an actual missile threat and intentionally sent the live alert (as opposed to believing that it was a drill and accidentally sending out the live alert)," it added.
The FCC was also critical of HEMA's failure to develop "standard procedures" to cancel a false alert and said "the error was worsened by the delay in authoritatively correcting the misinformation."
In the future, the FCC said, supervisors will receive advance notice of all drills and two warning officers will validate alerts instead of one.
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