Poor communication, understaffing, a lack of adequate planning and chaotic conditions contributed to the 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 broke out.
The 132-page report released Thursday 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,” poor preparation and the fact that the satellite-outlined “fire front” hadn’t entered west Altadena until 5 a.m., after evacuation alerts were issued, though several spot fires were confirmed in the area earlier in the night.
The independent investigation by consulting firm McChrystal Group, released eight months after the Los Angeles area firestorm, came after The Times revealed that the county didn’t issue evacuation alerts in west Altadena until hours after smoke and flames from the Eaton fire had threatened the community.
While 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. Some zones didn’t receive alerts until almost 6 a.m., hours after people began reporting fire in the area to 911.
Officials told The Times that the responsibility to issue evacuation orders was split among three agencies: the Los Angeles County Sheriff’s Department, the Los Angeles County Fire Department and the county Office of Emergency Management.
But Los Angeles County Sheriff Robert Luna later downplayed his department’s role, saying firefighters typically take the lead because they are “the experts” in such situations. The Office of Emergency Management, which is in charge of sending out alerts, said there were no technical issues.
Without assigning blame or explaining what went wrong, the report confirmed that between 1 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.”
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 Los Angeles County Fire Department obtained by The Times.
The report said that the initial calls for fire did not match the location of destroyed structures, appearing 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.
The reports provides two examples of Fire Department staff flagging that the fire may be burning west more than an hour before evacuations alerts went out for west Altadena.
A Fire Department staff member in the field in Altadena said they suggested to Unified Command staff a little before midnight on Jan. 8 that, due to high winds, evacuation orders should go out for the foothills of Altadena, all the way to La Cañada. Unified Command staff said 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 county Fire Department radioed in that they saw fire north of Farnsworth Park moving west along the foothills.
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 said: “No official form or documentation was used by LACoFD, LASD or OEM to jointly and formally record which zones should receive evacuation orders or warnings, the time the decision was made, or the time the zones were communicated to OEM staff at the EOC.”
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 warn against this, as have experts, repeatedly.
The report said that based on satellite data from the National Guard, the fire front did not cross into western Altadena until around 5 a.m., two hours after evacuation orders had been issued. The report acknowledged that 911 calls were coming in from the area hours before the orders, but categorized those incidents as “spot fires.”
The report repeatedly mentions how conditions created a “perfect storm” for firefighters, while highlighting that there seemed to be a real focus about NASA’s Jet Propulsion Lab in La Cañada Flintridge catching fire, which could release toxic fumes if ignited.
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 stated.
The report also claims 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 report found several problems with how the county carries out evacuations.
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 pointed out that, for the population it serves, the county’s Office of Emergency Management was considerably smaller than such agencies serving even smaller jurisdictions. “Compared to OEMs in jurisdiction of similar size (although not as large or complex), the Los Angeles County’s OEM has significantly less staff, budget and autonomy over its operating capabilities,” the report found.
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 found. 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 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.
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,” said one woman.
In 2019, almost a year after the Woolsey fire, a similar report prepared by Citygate Associates detailed how multiple simultaneous fires strained first responders’ ability to prioritize where to send people. The blaze destroyed some 1,600 structures and killed three people.
Similar issues were found with the county’s response this January, according to the 2025 report. Both reports questioned the wisdom of further development in fire-prone areas, given officials’ stated inability to defend the vast number of Californians who live within high-risk areas.
A Times investigation also found that most county fire trucks didn’t shift into west Altadena until long after it was ravaged by fire. Many county fire trucks had already been deployed to the Palisades fire and to east Altadena. Los Angeles County Fire Chief Anthony C. Marrone said the lack of fire trucks in west Altadena probably boiled down to “human error” by fire officials who decided where the trucks should move.
This story originally appeared on LA Times
