A report released by the staff for the Washington Utilities and Transportation Commission prompts critical concerns over CenturyLink’s outsourcing of pieces of its 911 network to Colorado-based Intrado.

Last week’s report examined the statewide 911 outage across Washington state that happened April 9-10, and the analysis details how 6.9 million residents of Washington state lost the ability to call 911 from landline, wireless and Internet-based telephones.

The outage had real effects in counties throughout the state, from heart attack and assault victims trying to call 911 for help to those who had seen vehicle crashes and were trying to alert emergency responders.

Here in Kitsap County, the report notes, people involved in a car crash tried to call 911 during the outage but were unable to reach dispatchers, and an aid car at the scene also couldn’t get through. At Harrison Medical Center, workers tried to report a patient who had overdosed but could not reach 911.

While investigators admitted the full impacts of the outage may never be known, at least 5,840 attempted 911 calls failed to properly reach emergency services during the outage in Washington.

“It will likely never be known the true extent of the harm to the public. Thousands of callers reached out for help and did not receive it. CenturyLink failed to ensure that the 911 system was fully operational and all possible backup systems were operational,” the report states.

The WUTC said the unprecedented six-hour 911 system outage was caused by errors that started in a data center owned and managed by CenturyLink’s 911 vendor. The report said the 911 system failure was “due to a foreseeable and preventable technical error and related deficiencies.”

Another disturbing aspect of the report was the revelation that CenturyLink didn’t promptly notify 911 call centers that the 911 system had gone down.

Staff for the utility commission have recommended a penalty up to $2.9 million for 11,731 violations of commission laws and rules.

The penalty seems in line with the seriousness of the outage, and the commission should heed the advice of staff and pursue the penalty as well as order the recommended improvements to the infrastructure of the 911 system, and require annual reports on maintenance and inspections of the system.