A series of outdated policies, weaknesses and systemic vulnerabilities hampered the effectiveness of emergency notifications and evacuation orders during January's devastating and deadly Eaton and Palisades wildfires, according to a county-commissioned independent review released Thursday.
The report is available HERE.
The "Independent After-Action Report" was commissioned by the Board of Supervisors and produced by McChrystal Group, a consulting firm led by retired four-star Gen. Stanley McChrystal. The firm was charged with conducting "an independent after-action review of alerts and evacuations" to provide "a comprehensive picture of actions taken during the catastrophic January wildfires along with recommendations to help guide future Los Angeles County responses."
Some concerns arose during and after the fires regarding the effectiveness of community notifications in terms of evacuation warnings and alerts -- particularly following warning messages that were accidentally transmitted to thousands of residents across the Southland who weren't intended to receive them. Questions also arose regarding the effectiveness or absence of warnings for many Altadena-area residents at the onset of the Eaton Fire.
The report noted that investigators found "no single point of failure" relating to public alerts, warnings and notifications.
"Instead, a series of weaknesses, including outdated policies, inconsistent practices and communications vulnerabilities impacted the system's effectiveness," according to the report. "These systemic issues did not manifest uniformly across the two major fires. The effects of these weaknesses varied based on environmental conditions, community readiness and operational complexity caused by the variables of wind, power outages and fire behavior."
The report's authors outlined key differences in the Palisades and Eaton fires, noting that the Palisades blaze erupted during daylight hours in a community that was familiar with wildfire risks. The Eaton Fire, however, occurred at night in an area not traditionally associated with severe wildfire danger.
"Some residents in Altadena reported receiving little or no warning before the fire reached their neighborhoods," according to the report.
"Beyond alerting and evacuation operations, this review identified systemic issues that impacted the alert and evacuation response," the document states. "Outdated and inconsistent policies, protocols and standard operating procedures created ambiguity around evacuation authority and responsibilities. In many cases, decision-making roles were unclear, and pre-incident public messaging responsibilities lacked standardization across agencies. These gaps contributed to nonuniform preparedness strategies across jurisdictions and slowed coordinated efforts."
The report also cited "longstanding challenges" regarding training, staffing, resource management and interagency cooperation that "further strained the response."
"During this review, law enforcement and emergency managers reported inconsistent training around wildfire evacuations, highlighting the need for cross-disciplinary exercises and clearer staffing models for surge scenarios," the report states. "Equipment and personnel shortages were magnified under the extreme conditions of this incident. Compounding this were gaps in situational awareness tools and communications interoperability, which impaired real-time coordination."
Some residents reported "confusion and frustration" over inconsistent messaging from authorities, and a lack of clear situational updates.
"Future preparedness efforts will require a more integrated approach to public information in collaboration with interagency and community partners to enhance clarity," the report states.
The report specifically pointed to resident complaints that emergency alerts and warnings failed to provide "complete information," including exact locations of evacuation zones -- an issue compounded by character limits in text/push alerts that required recipients to click on a link to obtain further details.
The rapid spread of the fires also left incident commanders unable to keep up and issue timely evacuation warnings and orders. As a result, some residents were left with "little time to prepare and evacuate," the report found. Some areas did not receive evacuation warnings at all before many residents had already decided to leave.
"This contributed to confusion and panic, with many evacuating residents feeling that they had little time to collect essential belongings," the report states.
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Power outages -- some planned for fire safety and others caused by the conflagrations -- also hampered some residents' ability to receive emergency notifications, according to the report.
"Residents reported that evacuations were chaotic due to a lack of clear instructions in evacuation messaging, and many reported that they evacuated based on their own observations or advice from neighbors rather than on official guidance," according to the report. "Some said that while evacuating, they encountered blocked roads and did not witness any emergency personnel helping to direct traffic -- this applied to both the Eaton and Palisades fires. Many reported having no support from first responders to evacuate and experiencing difficulties navigating through smoke, fallen trees and debris."
The wildfires killed 31 people and destroyed 16,251 properties in Altadena and Pacific Palisades, along with parts of Los Angeles, Pasadena, Sierra Madre and Malibu.
The report stressed that despite the identified breakdowns in communications and training, "frontline responders acted decisively and, in many cases, heroically, in the face of extraordinary conditions."
Los Angeles County Sheriff Robert Luna issued a statement that called the review an important tool.
"The Palisades and Eaton Fires were the worst natural disaster in our county's history, and it tested us and our community in every possible way," Luna said. "This After-Action Report is not only a reflection about the past, but it's a tool for building a stronger emergency response. It highlights what went well and identifies where we can improve, with a focus on enhanced cross training and better technology to strengthen our preparedness. I'm deeply proud of how our deputy sheriffs performed with professionalism and dedication under dangerous and extraordinary circumstances, which exemplifies the strength and resilience of our department, and how we serve our communities."
The Board of Supervisors is scheduled to discuss the review and its findings and recommendations at the board's regularly scheduled public meeting on Tuesday.
At a news conference Thursday afternoon, Supervisor Kathryn Barger, the board chair, said she would be introducing a motion at the meeting calling for the immediate implementation of recommendations included in the report, with an emphasis on expanding and bolstering the capabilities and technology in the county Office of Emergency Management.
"This will help us right-size and deliver emergency services to more than 10 million residents that Los Angeles County serves," Barger said. "It will also help us better define and establish the roles and responsibilities between first responders and our emergency management. We are living in an age where we must be ready to face the ever growing threat of wildfires and other disasters. With winter coming, I am now concerned about mudslides in the Altadena area. And let us not forget, earthquakes continue to happen. Emergency management professionals should be resourced to work directly with our first responders. Our emergency management systems must achieve clarity and be supported by robust training.
"We must also update our technological tools to ensure our county is using cutting-edge technology during these emergencies," she said.
Shawn Tyrie of the McChrystal Group noted during the Thursday news conference that the county's Office of Emergency Management has only 37 staff members -- in a county of 10 million residents. He said by comparison, New York City has 200 such workers for an area smaller in both size and population.
Supervisor Lindsey Horvath said the report marks the beginning of a continuing evaluation of "how we keep Angelenos safe."
"From this report, it is clear we must clarify our protocols for evacuations and alerts," she said. "We must practice and train as a region even more than we already do. We must communicate early, often and with one voice. We must invest in technology, infrastructure and most importantly in the people who expect us to keep them safe. And above all we must act. This report gives us a roadmap."
Tyrie said the report includes recommendations in five primary areas, relating to:
-- ambiguity in authority for issuing emergency alerts;
-- training and staffing guidelines to improve emergency response;
-- resource and staffing shortfalls in the emergency management system;
-- the lack of coordinated tools and systems to coordinate communications among first responder and emergency management personnel; and
-- fragmented community engagement and public information procedures.
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