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<td><a href="https://misportal.jlab.org/ll/index.jsf?function=view&lessonId=1176">CST-22-0414: Recent Emergency Communications Failures</a></td>
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<h2 style="white-space:nowrap">Statement of Lessons Learned</h2>
<pre>In a 6-week period, from March 03 through April 14, 2022, Jefferson Lab experienced a series of communications failures related to software issues during an Active Shooter, Site Alert Tornado Siren, and Accountability drills. The failures did not result in any injuries. </pre>
<h2 style="white-space:nowrap">Discussion of Activities</h2>
<pre>March 3, 2022 - The first failure occurred during an Active Shooter Drill:
- ~11:00am security guards attempted to activate the notification for Site-wide Alert for Active Threat.
- The system failed to execute the test and returned an error.
- ~11:10am Information Technology (IT) stated that there was "a bug" in the notification code that prevented security guards from sending site wide alert messages.
- IT fixed the error
- ~4:30pm the test was successfully executed.
March 8, 2022 - The second failure occurred during a Tornado Siren test:
- ~10:00am security guards attempted to trigger the Tornado Siren test.
- The siren did not activate and the system returned an error message.
- IT was notified and resolve the issue.
- ~10:14am the security guard was able to perform the test successfully.
April 14, 2022 - The third failure occurred during an Accountability Drill:
- The Emergency Manager attempted to activate the Accountability Drill notifications using the software tool.
- The system sent out only email communications, it did not send text/pager communications.
- IT stated that they had resolved the communications failure caused by a bug in the software code.
- ~1:40pm the notification system successfully sent out messages to two (2) previously unaccounted for employees, both of whom confirmed receipt of the text.
</pre>
<h2 style="white-space:nowrap">Analysis</h2>
<pre>The emergency drill infrastructure consists of both physical systems (alarms, sirens, electronic circuitry) and software programming. Both systems require maintenance and occasional replacement to keep pace with technology, improve reliability, and sustain optimal performance. The systems are required to be online to the greatest extent possible.
To avoid false alarming, and notifications when the software systems undergo changes and revisions, they are tested in a "development environment." This isolates them from their physical counterparts. This isolation introduces two (2) areas for potential error:
1. Work Environment - In the development environment, the Programmer is unable to confirm the software's relationship to the physical equipment. The developer environment does not lend itself to support any form of instrumentation that would indication that the software code modifications are compatible with the current physical components.
2. Actual System Response - After manipulation, the programmer cannot readily determine how the system will actually function when it is reconnected to the physical components. There are segments of code that have limiting functionality. These appear to work in the development environment, but are ineffective when released in the actual environment, because they retain their limited capabilities.
The effect of these error precursors is compounded by the fact that the work of the Programmer is performed in the knowledge-based performance mode. Human error occurs in this mode at a high frequency.
</pre>
<h2 style="white-space:nowrap">Recommended Actions</h2>
<pre>It is recommended that Jefferson Lab widen its boundary perspective for live drills to include not only employee response opportunities but also as an opportunity to uncover potential weaknesses within an emergency system. Due to the realities of the change-management protocols, drills currently represent the only environment in which to accomplish this. In a true learning, high-reliability culture, the uncovering of weaknesses during drills and tests is as beneficial, if not more so, than those drills that proceed without issue. </pre>
<h2 style="white-space:nowrap">JLab Preventive Measures</h2>
<pre></pre>
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<h2>Comments</h2>
<h5 style="white-space:nowrap">6/2/2022 1:19:42 PM by Bailey, Mary Jo</h5>
<pre>Submitted to those current in SAF505: Familiarity with Duties of Emergency Management Team Members</pre>
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<fieldset>
<legend>Summary</legend>
<table>
<tr class="row">
<td class="label" nowrap>Lesson ID:</td>
<td class="dataval">1176</td>
</tr>
<tr class="row">
<td class="label" nowrap>Status:</td>
<td class="dataval">OK</td>
</tr>
<tr class="row">
<td class="label" nowrap>Doc ID:</td>
<td class="dataval">2022-JLAB-1176</td>
</tr>
<tr class="row">
<td class="label" nowrap>Priority:</td>
<td class="dataval">Best Practice</td>
</tr>
<tr class="row">
<td class="label" nowrap>Safety Related:</td>
<td class="dataval">NO</td>
</tr>
<tr class="row">
<td class="label" nowrap>Originator:</td>
<td class="dataval">Bailey, Mary Jo</td>
</tr>
<tr class="row">
<td class="label" nowrap>Issued:</td>
<td class="dataval">5/5/2022 10:14:13 AM</td>
</tr>
<tr class="row">
<td class="label" nowrap>Approved By:</td>
<td class="dataval">Bailey, Mary Jo</td>
</tr>
<tr class="row">
<td class="label" nowrap>Approved On:</td>
<td class="dataval">6/2/2022 1:19:42 PM</td>
</tr>
<tr class="row">
<td class="label">Source:</td>
<td class="dataval">
TJNAF NE
</td>
</tr>
<tr class="row">
<td class="label" nowrap>Location:</td>
<td class="dataval">TJNAF</td>
</tr>
<tr class="row">
<td class="label" nowrap>Cost Savings:</td>
<td class="dataval"></td>
</tr>
<tr class="row">
<td class="label" nowrap>Contact:</td>
<td class="dataval">Amber Boehnlein, Associate Director Computational Sciences and Technology, Amber@jlab.org</td>
</tr>
<tr class="row">
<td class="label" nowrap>Queued Emails:</td>
<td class="dataval">149</td>
</tr>
<tr class="row">
<td class="label" nowrap>Sent Emails:</td>
<td class="dataval">0</td>
</tr>
<tr class="row">
<td class="label" nowrap>Viewings:</td>
<td class="dataval">4 times</td>
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<ul class="lesson_attribute_listing">
<li>Other: fires, emergency responses</li>
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<legend>Skills</legend>
<ul class="lesson_attribute_listing">
<li>SAF505: Familiarity with Duties of Emergency Management Team Members</li>
</ul>
</fieldset>
<fieldset>
<legend>Distribution/Notification</legend>
<ul class="lesson_attribute_listing">
<li>*Division Safety Officers (DSOs)</li>
<li>*Safety Wardens</li>
<li>*DOE Notification</li>
<li>*ESH&Q Liaisons</li>
</ul>
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