The Eaton Fire: How the system failed Altadena

A long-awaited Los Angeles County investigation has examined what went wrong in the response to the L.A. firestorm, where the Palisades and Eaton fires wiped out large swaths of the city and county and left 31 people dead.

On Jan. 7, a series of fires broke out amid extreme red flag conditions, overwhelming first responders and residents. Thousands of homes were destroyed.

In the aftermath, a Times investigation revealed that neighborhoods in west Altadena, which was under siege from the Eaton fire, did not get evacuation warnings for hours after the fire started and well after some blocks were burning. Almost all of the deaths from the fire occurred in this area.

The report released Thursday attempts to explain how things went awry. It did not blame specific individuals — something residents demanded — but did outline systemic failures involving multiple agencies. Multiple L.A. city agencies declined to sit down for interviews, the report states.

In the end, the report — by consulting firm McChrystal Group — confirms Times reporting from the last few months rather than uncovers any major revelations.

But some questions remain: Whose duty was it to issue more alerts and why exactly did they not?

Failure to evacuate

• Despite emergency dispatchers receiving at least 14 reports of fire in the area at the time, according to county records, the investigation confirmed that between 1 a.m. and 3 a.m. on Jan. 8, the county did not send out any evacuation alerts — including to west Altadena. The report said that at that time, “all areas [L.A. county fire officials] believed were directly impacted by or at risk from the Eaton Fire had already received an evacuation warning or order.”
• Outdated policies led to unclear decision-making roles regarding who had the ultimate authority to issue evacuation orders and warnings, especially concerning specific zones. That led to delays and inactivity. The report found that at the heart of the problem was the unclear evacuation roles for the Sheriff’s Department, county firefighters and emergency management personnel, the report said.Abandoned beds and wheelchairs on a front lawn and sidewalk. (Gina Ferazzi/Los Angeles Times)Inadequate staffing
• The Los Angeles County Office of Emergency Management has just 37 staffers for more than 10 million people, which is dwarfed by New York’s 200-plus-employee operation. Chicago and Cook County, Ill., both have more staff and resources.
• “Los Angeles County’s OEM has significantly less staff, budget, and autonomy over its operating capabilities. It is not just personnel it lacks but basic resources and even vehicles,” the report said. “Inadequate resources extend beyond personnel numbers to basic operational resources. OEM currently lacks funding for the proper PPE necessary for staff deployment to command posts during emergencies and lacks the vehicles needed.”
• Staffing shortages in law enforcement and emergency management limited the ability to conduct door-to-door notifications and manage traffic during evacuations. Deputies and firefighters were stretched thin, managing seven fires simultaneously.

Internet issues

• The lack of internet access at the command post led to a lack of communication and knowledge, several of those interviewed told the report’s author.

What reforms are occurring

Fire

• The county Fire Department has incorporated FireGuard, a National Guard satellite program, into its electronic incident command management platform.
• The department has contracted for satellite-enabled hot spot tracking capability. (Although this technology is not yet able to provide real-time tracking information, the department expects this tool to provide the data as the technology matures.)
• The department is contracting to develop an updated computer-aided dispatch system that connects with other first-responder systems and relays 911 call information to incident commanders more quickly.

Sheriff

• In April, the Sheriff’s Department launched a comprehensive tracking tool called the Citizen Evacuation Tracker to provide real-time visibility into who has been evacuated, who needs to be evacuated and where resources are needed most. This tool is now in use throughout the department.
• The department is configuring and testing its updated computer-aided dispatch system, which is expected to be implemented at patrol stations this year or early 2026.

Emergency management

• The Office of Emergency Management has begun sending evacuation warnings to zones adjacent to evacuation order zones at the direction of incident command. If this had been enacted in the Eaton fire, much of west Altadena would have received an evacuation warning at 9 p.m. on Jan. 7, more than six hours before evacuation orders came. No evacuation warnings were ever issued in west Altadena.

Remaining questions

• The report states that a Jan. 8 2:20 a.m. radio call from fire officials describing an incursion west in the hills around Farnsworth Park ultimately led to the evacuation order. Emergency Management officials said they were told to issue the alert around 3 a.m., 40 minutes after the radio call. The report does not explain why it took over an hour to enact the alert..
• The Times reported that at 3:08 a.m. on Jan. 8, as flames spread through west Altadena, there was just one county fire truck in the area. Because the Los Angeles Fire Department, the city of Pasadena, and the U.S. Forest Service declined interviews for this report, it is unclear what other resources were in the area.