The long-awaited Los Angeles County report examining the botched evacuation alerts in Altadena during the deadly Eaton fire cited a long list of shortcomings, from preparation to tactics.
But the after-action report into the fire that killed 19 people — all but one of them in west Altadena — stopped short of singling out individual leaders for those issues, and it failed to provide a detailed explanation for why evacuation orders in west Altadena came hours after smoke and flames started to threaten the area.
While the report, by Virginia-based consulting firm McChrystal Group, confirmed The Times’ reporting that first revealed the late evacuation orders, it did not detail exactly who or what was responsible for the breakdown, which county officials have previously called “an epic fail.”
That lack of blame appears to have arisen by design, despite fire victims’ repeated calls for accountability.
“This report does not investigate wrongdoing or assign blame,” the authors state at the beginning of the 132-page report, commissioned by the L.A. County Board of Supervisors at a cost of $2 million and released Thursday. “Its purpose is to assess the County’s alert and evacuation systems … and provide actionable recommendations to strengthen future response efforts.”
L.A. County Supervisor Kathryn Barger, who represents Altadena, called for the review after The Times reported in January that almost all the Eaton fire deaths occurred on the unincorporated town’s west side. In her motion, Barger cited “questions that have arisen” about the evacuation process.
After reviewing the after-action report, she said she was pleased with its findings, calling it an “in depth” report that “delivered a holistic picture of what worked and what didn’t.”
She acknowledged that many residents were frustrated that the report didn’t squarely apply blame for the late evacuation orders.
“There is no one smoking gun, and I know that’s problematic for people to understand,” Barger said at a news conference Thursday. “There’s no question that there were failures, but it was not one specific individual or one specific department that can have an, ‘Off with your head.’ At the end of the day … it truly was the perfect storm.”
But some experts and many Altadena residents worry that the report’s lack of specificity helps officials dodge accountability and makes it more difficult to ensure that such a catastrophic failure doesn’t happen again.
“Somebody needs to take responsibility, and nobody does that because they want to protect their authorities,” said Art Botterell, who retired in 2018 from the California Governor’s Office of Emergency Services as senior emergency services coordinator. “Responsibility just gets you hurt. So there’s a tendency to avoid that.”
Shawna Dawson Beer, who lost her home in northwest Altadena, said the report repeatedly shielded county officials, particularly fire and sheriff’s officials, from any real accountability.
“We want to know WHO was responsible,” Beers wrote in a social media post on her Beautiful Altadena page. “Name the officials. Identify the decision-makers. … This isn’t about blame, it’s about responsibility.”
Mark Douglas, another west Altadena resident who lost his home in the fire, said he had low expectations for the report, despite how long it took. But he was still disappointed that it included almost no answers about why his community received evacuation alerts hours after homes were on fire.
“We were all wondering and promised an explanation as to why they didn’t go out,” Douglas said.
He said he wasn’t looking to blame rank-and-file firefighters and sheriff’s deputies, on a night when they were also battling Palisades fire, protecting eastern Altadena and rescuing countless people in both fires. But he was shocked to see no one named or quoted in the report — not even agency heads.
The report’s authors interviewed 147 people from the community and the agencies most closely involved in the evacuation alerts — the L.A. County Fire Department, the L.A. County Sheriff’s Department and the county Office of Emergency Management. But the report did not name any officials, not even Fire Chief Anthony Marrone or Sheriff Robert Luna.
Douglas said he would like to hear directly from these officials in a setting where community members can directly address them and get answers.
The report found that a little before midnight, a staff member from the L.A. County Fire Department suggested to the fire’s “unified command” staff that, due to high winds, evacuation orders should go out for most of the San Gabriel foothills, including all of Altadena.
But unified command staffers said they didn’t recall this. Two hours later, another fire staffer radioed that they saw fire north of Farnsworth Park, moving west along the foothills into west Altadena.
Not until 3:25 a.m. did most west Altadena residents receive an evacuation order.
The report did not say why the midnight recommendation wasn’t received or acted on, or why it took more than an hour for the second radio call to be sent as an evacuation order. It did not say who was responsible for those decisions or if others should have stepped in.
The report did cite communication breakdowns, unclear designation of responsibilities, insufficient resources and chaotic conditions as factors in the lapses, while providing recommendations for how to address those big picture shortcomings in the future.
“There was this breakdown in the system. … There is no one individual that you can point to and say, ‘You failed at your job,’” Barger said. “It was a combination of many things taking place, including the way this fire was acting.”
Ron Galperin, a former Los Angeles city controller who produced reports on the city’s emergency alerts in 2018 and 2022, disputed the idea that the report did not assign blame.
“What it points out is that there is a lot of blame to go around for everyone,” he said, noting that L.A. County fire, sheriff and emergency management officials all played a role, along with the California Department of Forestry and Fire Protection and other local, state and federal authorities that pitched in. “So many different parties are involved here, that, in fact, there is plenty of blame to go around.”
Barger agreed, saying that looking at the big picture issues will be most helpful.
“Lasting improvements won’t come from pointing to a single error — they’ll come from addressing the broader processes and communication gaps that the report identified,” she said.
“I appreciate that the McChrystal Group’s report provided recommendations [that] are specific and actionable, especially regarding what needs to be done to improve coordination and collaboration across County departments,” she added. “That’s where my focus is now — making sure we implement those changes, so our Los Angeles County residents are safer in the future.”
Thomas Cova, a geography professor at the University of Utah in Salt Lake City who specializes in environmental hazards and emergency management, said it’s likely that officials will never answer the big questions lingering over the Eaton fire: Why were evacuation orders to west Altadena so delayed, and who was responsible?
“They’re going to say that we don’t want to play the blame game,” Cova said. “If this kind of thing happened with a surgeon, or if this kind of thing happened with an air traffic controller, would they just say we need more training for the person or would they say that we need to get somebody new because the public deserves better?”
Times staff writers Terry Castleman and Richard Winton contributed to this report.
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