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False nuclear alarm in Ontario was due to human error, investigation finds


TORONTO — A false alarm about an incident at the Pickering Nuclear Generating Station last month was the result of human error, but a delay in sending an all clear was due to several systemic issues, a report found Thursday.

The alert was pushed to cellphones, radios and TVs across the province on the morning of Sunday, Jan. 12.

The duty officer at the Provincial Emergency Operations Centre is supposed to test both a live alert and a training system at shift changes, and on that day the officer thought they had logged out of the live system and into the training one when the alert was sent, according to a report from the chief of Emergency Management Ontario.

The officer immediately realized the error and asked supervisors how to fix it, but they were uncertain about whether or how to send a corrective alert to everyone who had seen the first, the report said. Most supervisors didn't have access to the alert system or training on it.

"The findings revealed EMO procedural gaps, lack of training, lack of familiarity with the Alert Ready system and communication failures," the report found. "These findings can provide context to the (duty officer) error and the length of time — 108 minutes — that elapsed between the alert issued in error and the second clarifying alert."

Solicitor General Sylvia Jones acknowledged the systemic issues and said steps have already been taken to address them.

"I'm not happy about it, but at the end of the day I think that we have a better system, that we can give assurances to the people of Ontario that the system has been improved and ultimately we don't want it to happen again," she said.

Many of the report's recommendations have already been implemented, Jones said, but others will involve discussions with the Canadian Radio-television and Telecommunications Commission about the national alert system run by Pelmorex.

"What we saw in Ontario could happen in other places, so we need to ensure that those changes happen at a national level," she said.

A timetable in the report from the morning of Jan. 12 shows a flurry of communications between three employees, six supervisors, and staff at Pelmorex, often with conflicting advice. Pelmorex staff "consistently" told the emergency management staff not to send a second alert through the alert system because the original warning had "expired," the report said.

"Pelmorex's role on January 12, 2020 exceeded advice on technical use of the Alert Ready system and included advice on how and whether to issue alerts," the report found.

The company said it was asked that day to comment on the use of a second "broadcast intrusive message" — which would send the notification to everyone who had seen the first one — and it provided a recommendation.

"However, it is at the sole discretion of the authorized government issuer to determine if and when to issue a broadcast intrusive 'end of alert' message," the company said.

"We are reviewing the findings that were identified in the report and will work with all federal, provincial and territorial Alert Ready partners to evaluate potential solutions to ensure that the Alert Ready system continues to be used, as intended, to notify the public of life-threatening situations."

Corrective steps already taken by the ministry include clearly labelling test messages in the alert system, requiring separate log-in credentials for the live and training systems, more training — including for supervisors, and establishing a new procedure for an "end alert" message in case of future errors.

The ministry will also conduct a review of staffing at the Provincial Emergency Operations Centre. The report found that duty officers worked long hours. On Jan. 12, the employee that sent the erroneous alert had worked seven consecutive days and three consecutive 12-hour shifts.

Both officers there at the time of the erroneous alert had been on the job for about six weeks, and a training program had been cut short to co-ordinate a provincial response for an emergency flood evacuation, the report said.

NDP Leader Andrea Horwath said she was concerned about the training shortfall and the government needs to work hard to regain the public's faith in the system.

This report by The Canadian Press was first published Feb. 27, 2020.

Allison Jones, The Canadian Press

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