District Investigates Button Press That Caused 911 Outage
The District of Columbia is reviewing its processes after learning human error led to a 100-minute outage of the 911 system in the District of Columbia over the weekend. The outage initially was reported as an equipment failure (see 1608290027). Now, a D.C. Office of Unified Communications spokesman said officials have determined the failure was caused by a contractor hitting an emergency shutoff button. A National Emergency Number Association official said developing standards and best practices for 911 centers could prevent similar outages at other such centers.
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It appeared to be an accident, but the individual responsible “has been removed from operating within any District building as a worker in the capacity he was working over here,” the OUC office spokesman said. “What happens to him from a professional perspective is up to his employer.” The office also plans to improve labeling of the button, he said.
Mayor Muriel Bowser (D) “ordered a top-to-bottom examination of the processes involved here,” and OUC Office Director Karima Holmes “is leading an investigation to … confirm exactly what happened and then to examine all of the issues that have arisen based on this event,” the OUC office spokesman said. Once it completes the probe, the office plans to release a “detailed steps-forward plan to make sure that first of all this doesn’t happen again, and that our current system is made even better,” he said. The OUC is coordinating with the D.C. Office of Homeland Security and Emergency Management on the investigation, he said.
“Any time that you have a system that is used for the safety of human life like 911, you have to be very careful and very thoughtful as you design in redundancies and resiliency,” said NENA Director-Government Affairs Trey Forgety in an interview. Some but not all 911 centers have procedures to prevent outages caused by human error, he said. "We would love to think that every 911 center has everything perfectly figured out … but there's an old saying in our field: 'If you've seen one 911 center, you've seen one 911 center.' They are all completely different." Some centers have policies and procedures for handling every possibility, but others operate "much more fluidly,” he said. “Both are equally valid ways of doing business, but I do think at the end of the day, having more things that are written down and carefully thought through can prevent outages that are caused by human errors.”
It would be tough to mandate​ a set of operating procedures for 911 centers, but it's possible to develop national frameworks allowing 911 centers to share best practices, said Forgety. "What you will see is much more use of frameworks to guide thinking … particularly as things like cybersecurity and system resiliency become much more prominent concerns in our space.” NENA could develop such a framework, he said. The organization plans to discuss 911 center standards and best practices at an October conference in Columbus, Ohio, he said.
Human error may be to blame for the D.C. outage, but NENA members have reported anecdotally that an aging phone infrastructure is becoming more fragile and could be causing problems, Forgety said. There isn’t much data available on 911 outages, but new FCC outage reporting rules (see 1608290045) could soon fill this gap, he said. "The increased frequency of major outages, whether they're in the [public safety answering point] systems or in the networks, are evidence of the need for quick and concerted action on the transition” to next-generation 911, he said.