HONOLULU -- Hawaii's nuclear missile scare showed that the state began testing alerts before fully developing a plan to address the ballistic missile threat and that a public outreach campaign months earlier wasn't effective, said a report released Tuesday.

The state Department of Defense, the agency that oversees Hawaii's emergency management, released the internal review after an alert was sent to cellphones, televisions and radio stations across the state last month.

The notification, which read "BALLISTIC MISSILE THREAT INBOUND TO HAWAII. SEEK IMMEDIATE SHELTER. THIS IS NOT A DRILL," triggered widespread panic as more than a million residents and visitors feared they were about to face a ballistic missile strike.

Gov. David Ige assigned Brig. Gen. Kenneth Hara, the second in command at the Department of Defense in Hawaii, to conduct a comprehensive review of the agency's operations.

"The response and recovery sections of the plan were minimally developed," Hara's report said. "The plan lacked clear details for sheltering, county coordination and protocols for decision to send out all clear or false missile alert messages, e.g., interception, missile impact without effect to Hawaii, etc."

The public didn't get adequate directions about what to do, the report said.

An agency employee mistakenly sent the alert to cellphones and broadcast stations across the state during a shift-change drill at the agency on Jan. 13.

Officials later disclosed the employee didn't think he and his colleagues were participating in a drill and instead believed a real attack was imminent. The state has since fired him.

State officials said the worker, who had been employed at the agency for 11 years, had mistakenly believed two prior drills -- for tsunami and fire warnings -- were actual events. His supervisors counseled him but kept him for a decade in a position that had to be renewed each year.

The ex-worker disputed that, saying he wasn't aware of any performance problems. The employee, who spoke on condition of anonymity because he feared for his safety after receiving death threats, told reporters that he was devastated about causing panic but was "100 percent sure" at the time that the attack was real.

Some managers didn't follow proper procedures to deal with unsatisfactory performance, which contributed to the false alert, the report said.

Hara's report recommends employee development training for supervisors and managers.

The agency's administrator, Vern Miyagi, resigned on Jan. 30. The agency's executive officer, Toby Clairmont, resigned shortly after the incident because it was clear action would be taken against agency leaders, he said.

A fourth employee was suspended without pay.

It took the agency 38 minutes to send a follow-up message cellphones notifying people the alert was a mistake, in part because the agency had no prepared message it could send out in the event of a false alarm. Agency officials notified broadcast stations earlier.

Within hours of the alert, the agency changed protocols to start requiring that two people send an alert. It also made it easier to cancel alerts by preparing a pre-programmed false alarm message.

The report's recommendations include suspending all activities related to the Ballistic Missile Preparedness Campaign, with the exception of the monthly ballistic missile alert tone siren testing, until a plan is published and the majority of Hawaii's public know "what to do, where to go, and when to do it."

It also recommends reviewing the feasibility of reinstituting "fallout shelters." Hawaii stopped maintaining such shelters after the Cold War ended and funding ran out.

Although spurred by the missile scare, the report provides recommendations about all the hazards the islands face. Because Hawaii relies on nearly all of its goods to be imported, the report recommends improving ports and expanding distribution infrastructure, but notes doing so will be expensive and time-consuming.

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AP writers Caleb Jones and Audrey McAvoy contributed to this report.

This article was written by Jennifer Sinco Kelleher from The Associated Press and was legally licensed through the NewsCred publisher network. Please direct all licensing questions to legal@newscred.com.