The employee who sent out the false "incoming ballistic missile" alert to the state of Hawaii in mid-January has been fired, and Vern Miyagi, the administrator for the Hawaii Emergency Management Agency (HI-EMA), has resigned.

The incident, which left Hawaii residents in a panic for 38 minutes thinking a ballistic missile was bound for their state, was initially blamed on bad software—HI-EMA said that an employee had accidentally selected the wrong choice in a menu of confusing choices. The governor's office circulated two different mockups that illustrated the design that employees had to navigate to effectively work the system.

But then on Tuesday, the Federal Communications Commission released a preliminary report saying that the employee actually thought the internal announcement of an "exercise" was the real thing because the employee claimed not to have heard the "exercise" portion of the recording, which was followed by another recorded message stating "this is not a drill." The FCC admitted it couldn't vet the credibility of the employee's claim, because the employee refused to be interviewed by the FCC.

Now, a separate internal investigation released (PDF) by the Hawaii Emergency Management Agency on Tuesday suggests a more bizarre turn of events.

According to that report, "EXERCISE EXERCISE EXERCISE" was announced before and after the "this is not a drill" message on a speaker throughout the work area. Employees 1, 2, and 3 began running through the ballistic missile alert checklist and verbally announced when they completed simulated actions.

"Employee 1 logged into the AlertSense System and waited for Employee 3's announcement of the simulated siren warning activation. Following the simulated siren announcement, Employee 1 erroneously activated the real-world Alert Code," the report states. The false alert went out at 8:06.

Within the minute, employees on the floor began receiving warnings on their personal smartphones. Immediately, three employees checked to confirm that it was a false alert.

By 8:09, one employee was on the Hawaii Warning System that sends messages to broadcast stations, trying to tell those stations that a false alert had been sent. That employee started a roll-call to make sure all broadcast stations heard the message. By 8:12 the drama seemed to turn back to the employee who sent out the false alert, who was instructed to cancel the alert (the cancel message just prevents off-network phones that haven’t received the missile warning from receiving it when they rejoin the network, but it doesn’t send an all-clear message):

Employee 5 directed Employee 1 to send out the cancel message on AlertSense. Employee 5 stated that Employee 1 just sat there and didn’t respond… Employee 2 was on the phone with Employee 6 briefing them on the situation. Employee 5 was alerting the command staff. Employee 1 was sitting and seemed confused. Employee 3 took control of Employee 1’s mouse and sent the cancel message. At no point did Employee 1 assist in the process.

The internal report doesn't say what Employee 1 did after that, but the rest of the staff seems to have been frantically trying to notify all recipients of the message that it was a false alert.

In the internal report's analysis of the event, it seems that there were a couple factors at play. For one, "The AlertSense program replaced an older program in mid-December 2017. No technical training was provided to the SWP [State Warning Point], only basic application. Many SWP personnel felt that this training was inadequate."

More importantly, though, Employee 1 seems to have made this kind of mistake before. From the internal report:

Employee 1 has been a source of concern for the same SWP staff for over 10 years. Employee 1’s poor performance has been counseled and documented and the SWP members have stated that they are “not comfortable with Employee 1 as a supervisor, two-man team, or as a part of the SWP in general. He does not take initiative and has to be directed before he takes action. He is unable to comprehend the situation at hand and has confused real life events and drills on at least two separate occasions.”

Those two separate occasions aren't detailed in the report, but Honolulu Civil Beat says that the incidents happened "once during a fire incident test and again during a tsunami warning test," according to Brig. General Bruce Oliveira (who led the internal investigation). Neither incidents led to notifications sent to the general public.