‘Perfect storm’ caused botched evacuations during deadly Eaton fire, investigation finds

Poor communication, understaffing, a lack of adequate planning and chaotic conditions contributed to a failure to issue timely evacuation orders to parts of Altadena as the deadly Eaton fire raced through the community, according to a long-awaited report released Thursday.

The report did not assign blame to individuals for the botched alerts, but found Los Angeles County had no clear process for who should issue evacuation orders and called for significant reforms. Nineteen people died in the fire, all but one of whom was found in west Altadena, an area that did not get evacuation alerts until hours after the fire threatened the area.

However, the 132-page report seemed to downplay how early the fire threatened west Altadena — despite 911 calls that reported flames and smoke in the area — and only once mentioned the 19 people who died in the fire.

Instead, it focused on the fire’s “perfect storm,” officials’ poor preparation and the fact that the satellite-outlined “fire front” hadn’t entered west Altadena until 5 a.m. — nearly two hours after evacuation alerts were issued.

But those alerts came hours after several spot fires were confirmed in the area and well after some fire officials pointed out the area was at risk.

The independent investigation by consulting firm McChrystal Group — released eight months after the Los Angeles-area firestorm — was commissioned by the county after The Times revealed that the county failed to issue timely evacuation alerts in west Altadena.

“This McChrystal group report highlights the fact that we are not prepared if, God forbid, we have another emergency like this,” said L.A. County Supervisor Kathryn Barger, whose district includes Altadena, at a news conference about the report’s release.

She said there were many failures but no “smoking gun.”

Although areas east of Lake Avenue got evacuation orders just after 7 p.m. on Jan. 7, most of west Altadena did not receive any evacuation alerts until 3:30 a.m. the following day. Some zones didn’t receive alerts until almost 6 a.m., hours after people began reporting fire in the area to 911.

Many residents have told The Times they never got an evacuation alert and decided to flee after waking up to homes filled with smoke, or realizing their street was on fire. Some who left after they got the evacuation order said they only narrowly escaped.

Officials told The Times that the responsibility to issue evacuation orders was split among three agencies: the Los Angeles County Sheriff’s Department, the county Fire Department and the county Office of Emergency Management. But the report found there were no clear protocols indicating which agency, exactly, was ultimately responsible for issuing evacuation orders.

Going forward, the report recommends a simplified structure for evacuations: the Fire Department picks which zones to evacuate, the Sheriff’s Department makes sure the evacuations get done, and the Office of Emergency Management sends alerts.

“No report or review or article will accurately capture or reflect the absolute horror and tragedy that occurred and unfolded that night,” county Fire Chief Anthony Marrone told reporters Thursday.

He said he wanted to do a better job of tracking where 911 callers were reporting fire during a massive blaze like the Eaton fire, noting his agency’s technology to track these calls was more than 30 years old.

“We need to know where the 911 calls are coming from, and [be] able to seamlessly send that out to our incident commanders in the field,” he said.

Shawn Tyrie, a partner at McChrystal Group, said his company “did not look for wrondgoing or to place blame” when reviewing the county’s failures that night.

The report said that between 1 and 3 a.m. on Jan. 8, the county fire officials believed all areas “directly impacted by or at risk from the Eaton Fire had already received an evacuation warning or order.”

But that was not the case.

The first evacuation order for west Altadena came at 3:25 a.m. after dispatchers received at least 14 reports of fire in the area, according to 911 logs from the Fire Department obtained by The Times.

The report pointed out, though, that the initial calls for fire did not match the location of destroyed structures, and seemed to question the validity of those early calls and the presence of flames. The report claimed that the first 911 call for a fire in west Altadena where the structure was later confirmed damaged came just before 1 a.m. on Jan. 8 — still more than two hours before evacuation orders were issued.

At least two Fire Department staffers also flagged that the fire may be burning west more than an hour before evacuations alerts went out for west Altadena, according to the report.

A Fire Department staff member in the field in Altadena said they suggested to Unified Command staff a little before midnight that, due to high winds, evacuation orders should go out for the foothills of Altadena, all the way to La Cañada Flintridge. Unified Command staff said that they did not recall this occurring and that the fire front was not moving west at the time.

About two hours later, at 2:18 a.m., a staffer with the Fire Department radioed that they saw fire north of Farnsworth Park moving west along the foothills.

The report emphasized the chaotic nature of the night with hurricane-force winds scattering embers for two miles. Unlike the Palisades fire, the most grueling part of the Altadena fire fight was fought entirely at night with winds forcing all aircraft to be grounded by 6:45 p.m. This left first responders without a bird’s-eye view of the flames, significantly reducing their overall awareness of the fire’s movement.

“Ultimately, in a perfect world, we would have wanted zero lives lost. But unfortunately, disasters are rarely perfect,” Sheriff Robert Luna said Thursday. “There was no playbook for what we saw and experienced this last January.”

The report repeatedly mentioned how these conditions created a “perfect storm” for firefighters, and highlighted worries that NASA’s Jet Propulsion Lab in La Cañada Flintridge could catch fire and release toxic fumes.

While the fire initially burned eastward, firefighters soon reported that it was spreading “everywhere all at once” with wind gusts of 70 to 90 mph.

“Evacuation decisions and messages could not keep pace with the fire,” the report said.

The report also claimed that the fire entered west Altadena as wind speeds increased, describing it as a “more densely populated” area with older homes built with materials that were “more vulnerable to ignition.”

The manner in which the county carries out evacuations is deeply flawed, and its emergency management agency woefully underfunded, the report found.

Sometimes, when officials evacuated a zone, they would automatically evacuate the zone next to it. But that practice was not codified and did not happen in western Altadena.

The report also said that the Office of Emergency Management is small for the size of the population it serves.

Compared with emergency management agencies in similarly sized jurisdictions, the county “has significantly less staff, budget and autonomy over its operating capabilities,” the report found. Kevin McGowan, the director of the department, said Thursday the agency has six new positions hiring in final stages.

The three agencies in charge also did not have a single platform with which to coordinate communication, exacerbating issues with decision-making across the fire response, the report concluded. Sheriff’s Department staff may not have been aware in real time of which zones were under evacuation warnings or orders, as they were not always side by side with other agencies at Unified Command, according to the report. The command post also was without internet service, forcing officials to rely on calls and text messages to communicate.

The county had recently switched alerting systems and only four “less experienced” staff members knew how to use the new system, leaving it “less than optimally resourced for a catastrophic disaster,” the report stated. The Times had previously reported the county had made the switch to its new platform just three weeks after getting the software, raising questions about how long staff had to train on the new system.

There was also little written record of which zones should be evacuated and when the decision was made. Though some officials present in the decision-making process told investigators they had taken notes in the field about evacuation decisions, the notes “were either incomplete, not time-stamped, or not maintained.”

The report also mentioned — without naming specific people or agencies — that the county “had concerns about over-warning” during the fire, worrying about adding confusion, panic or unnecessary traffic issues. State guidelines on alert and warning systems explicitly tell emergency operators that “fear of triggering ‘panic’ is not a valid reason to delay or avoid issuing a warning.”

The report was conducted by the McChrystal Group, a consulting firm with experience assessing government response to natural disasters. The report included dozens of interviews with fire and county officials as well as public listening sessions. Several agencies involved in the fire declined to be interviewed, including the Los Angeles Fire Department, California Governor’s Office of Emergency Services, Sierra Madre Fire Department and Pasadena Fire Department.

During a May 7 listening session, residents repeatedly told the consultants that their evacuation orders had been dangerously delayed. “None of us really received alerts,” one woman said.

Some residents say the resulting report does little to answer why.

“It’s such a softball,” said Shawna Dawson Beer, who lost her home in northwest Altadena. “For anyone who lives in the community, there’s nothing in there that we don’t already know.”

“I’d like it to be a real investigation into what fell apart so it can be corrected,” she added.

Several of the recommendations in this report were previously outlined in a similar report following the deadly Woolsey fire in 2019, but they appear to have either never been implemented or been allowed to fall by the wayside.

The report also analyzed the county’s response to the Palisades fire but drew a stark comparison between what played out across the Santa Monica Mountains and in Altadena. Although the Palisades fire grew under similarly catastrophic winds, the report found officials made fewer missteps in the Palisades because the fire “ignited during daylight hours in a community familiar with wildfire risk” and benefited from “strong interagency coordination, pre-positioned resources and tested evacuation strategies.”

County Supervisor Lindsey Horvath, whose district includes the Palisades, said the report shows “where we fell short during the January wildfires and where we must do better.”

Mark Douglas, a longtime resident of west Altadena who lost his home in the fire, has been waiting for this report for months.

But on Thursday, he said the report’s narrative of a “perfect storm” and a “fire front” that didn’t officially enter west Altadena until 5 a.m. discredited his own experience the night of the fire and seemed to him to be a blanket excuse for all that went wrong.

Most concerning, he said, was the report’s lack of a specific explanation for what went wrong with the evacuations and its failure to name or quote the people who were directing resources and leading agencies.

“These wind-driven fires ... are not going away,” Douglas said. “We worry that nothing will change.”

Times staff writer Richard Winton contributed to this report.