Signs point to human error in Altadena evacuation failure

It is perhaps the most pressing unanswered question from Los Angeles’ January firestorm: How did officials fail to issue timely evacuation alerts for residents in west Altadena, where all but one of 18 Eaton fire deaths occurred?

Nearly five months after the deadly fire decimated Altadena, two possible scenarios have emerged as to what went wrong that chaotic night. Either there was some human error along the chain of command issuing evacuations or there was some type of technical error in sending the alerts.

An independent investigation was launched after The Times revealed the lapse in mid-January. But it’s unclear what investigators have since discovered, and county officials have repeatedly declined to answer questions and have delayed responses to public records requests, often citing the ongoing inquiry.

But there is growing evidence that the critical shortfall — in which flames moved into west Altadena hours before residents received any evacuation alerts — stemmed from human error, likely during the decision-making process, inter-agency communications, or both.

Last week, U.S. Rep. Robert Garcia (D-Long Beach) told The Times that human error appeared to be the cause of the delayed alerts in west Altadena. He spoke after releasing a report on evacuation alert issues during the firestorm, but noted his federal investigation did not look at the issues in Altadena. The probe initiated by L.A.’s congressional delegation focused primarily on a series of faulty evacuation alerts during the firestorm that erroneously urged millions of people across L.A. County — instead of a small group of residents near Calabasas — to prepare to evacuate.

Supervisor Kathryn Barger, who represents Altadena and has strongly criticized the delays, told The Times that she still doesn’t know exactly went wrong that night, but said she believes there was likely a “breakdown in the communication” among county fire, sheriff and emergency management officials — the agencies that jointly issue evacuation alerts.

Further pointing to a likely human failure, the chief executive of Genasys, the company that provides emergency alert software to the L.A. County’s Office of Emergency Management, told stockholders in March that the delayed alerts in west Altadena were not the result of a technological error.

County officials have not commented on that assertion — or others — citing the ongoing investigation being conducted by the McChrystal Group, an independent contractor that specializes in disaster management.

But as the probe has continued, there has been some quiet finger-pointing about what agency or issue may have been responsible for the delayed alerts.

An electronic evacuation order was not issued for west Altadena until around 3:30 a.m. Jan. 8, nearly nine hours after the fire broke out and several hours after smoke and flames threatened the area. Some neighborhoods in southwest Altadena weren’t ordered to evacuate until almost 6 a.m. Neighbors east of North Lake Avenue, located closer to the fire’s origin, received their first evacuation alert around 6:40 p.m. Jan. 7, according to a review by The Times.

Initially, officials mostly avoided speaking directly about what might have gone wrong with west Altadena. Instead, they described the night as pure chaos, struggling to keep ahead of a fire that quickly turned into a major urban conflagration, driven by erratic, hurricane-force winds that grounded aircraft early in the firefight. In the first few hours, the fire departments from Pasadena, L.A. County and the Angeles National Forest responded together to the brush fire that broke out in Eaton Canyon, not far from homes.

Within a few hours, officials entered into a larger unified command structure operating from the Rose Bowl as federal and state teams joined the response, as well as other local fire departments, the L.A. County Sheriff’s Department and the county Office of Emergency Management. Officials described a joint process among county fire, sheriff and OEM officials to determine necessary evacuations and ensure they were implemented, through both wireless alerts that ping cellphones within a certain geographic area and on-the-ground patrols.

But from about midnight to 3 a.m. — as the Eaton fire starting making a frightening run west — no electronic evacuation alerts went out.

No one has yet to explain what went wrong.

While Sheriff Robert Luna called the evacuation process a collaborative effort, in February he downplayed his agency’s role in the decision-making part, explaining that firefighters typically take the lead because they are closely tracking fire behavior, the blaze’s movement and associated weather.

“We are included in the decision-making, but they’re the lead,” Luna said in a prior interview. “Even though it’s unified command, I depend on the experts.”

But there’s also some concern about a gap between the efforts of some deputies on the group and central commanders. Several west Altadena residents told The Times that there were some deputies in their neighborhoods assisting with evacuations amid fiery conditions around 2 a.m., before the 3:30 a.m. alert went out. It not clear if those deputies failed to relay their surrounding conditions and the need for increased evacuations, or if that update was ignored.

Later, reporting from The Times revealed that the county’s Office of Emergency Management had only recently started using the Genasys system to issue wireless emergency alerts, going through less training and testing than other counties that implemented the system. Public records also showed that during the night of Jan. 7, there was only one person sending out alerts for the three fires that raged across the county: Eaton, Palisades and Hurst.

However, anonymous sources within county government told The Times that the west Altadena error wasn’t the fault of OEM officials. The sources said the OEM team sent out the evacuation order to west Altadena soon after it was ordered to do so — a revelation that appears to rest the blame on county fire or sheriff officials.

Luna declined to comment further on the situation, citing the ongoing probe.

County Fire Chief Anthony Marrone confirmed this week that he has been interviewed by the McChrystal Group, as have many of his command staff. But he said he hasn’t yet been told what went wrong.

“I’m waiting to see what they find,” Marrone said. “This is such a complex issue that I think, collectively, we all have to do better.”

In a recent interview, Pasadena Fire Chief Chad Augustin echoed what other command center officials have told The Times: that he didn’t remember a moment or point in the night when they realized they had made a mistake or messed up evacuation alerts for west Altadena.

Augustin said he did remember a major shift in winds that required the fire commanders to adjust as quickly as possible. He estimated that around 2 or 3 a.m. command staff at the Rose Bowl started receiving “good intel” from teams on the ground that the winds were shifting and pushing the fire west, requiring more evacuations, but he didn’t recall exact timing.

“You’re trying to do your best with taking in the fire, the direction of travel, the wind conditions,” Augustin said, noting that the winds remained extremely erratic the first 24 hours of the fire. “You had a bunch of leadership who are trying to make real-time decisions based on the intel that they’re receiving.”

Augustin said he expects the after-action report will find that any shortcoming from that night were from a combination of the fire shifting so rapidly and some delay in how the evacuation alert went out on the county’s electronic alert system.

“In a large-scale disaster like that, when you have a wind shift, you’re receiving the information and trying your best to make the best decisions possible,” Augustin said. You’re “making as many notifications based on the resources you have.”

Whatever new information comes out of the investigation, some residents say it won’t make a difference: No matter the probe’s outcome, they say, the damage has already been done.

“I don’t trust that anything really will come from it,” said Marisol Espino, a lifelong west Altadena resident who lost her family’s home in the January firestorm.

Some experts worry that public officials risk alienating more residents across Altadena by not providing answers. They worry that could jeopardize future evacuation efforts.

“If we’re now four months out and we don’t know what the heck went on in Altadena, then that is a significant problem,” said June Isaacson Kailes, a disability policy consultant familiar with Los Angeles emergency planning. “It significantly degrades trust … and people will also be hurt because they won’t trust the messaging.”

Barger, the L.A. County supervisor who represents Altadena, said she understands there’s frustration over the lack of answers, but said it’s critical that investigators are thorough.

“While I wanted this to be real quick, it’s not as simple as that,” Barger said. “In order for us to get this right, I want to make sure that we leave no stone unturned…. I’m going to give them grace until I get the report.”

The L.A. County Board of Supervisors initiated the independent investigation in early February, and called for the report to be made public within 90 days. At the end of April, the McChrystal Group presented an update on its investigation, detailing completed community listening sessions and a count of 33 interviews done and 18 to go. It provided no substantive information on what happened that night.

“I think the fact it’s been four months and they haven’t just come out and said it means there’s something behind the surface — sensitive information associated with liability,” said Thomas Cova, a professor of geography at the University of Utah who specializes in emergency alerts during wildfires. “It’s strange, I guess, that it’s taking this long. … But it’s probably a report that needs to be reviewed by everybody. And it is California — a pretty litigious culture.”

The night of the fire, Espino’s multi-generational family ended up evacuating around 9 p.m. — well before any official evacuation order — which at the time she attributed to being overly cautious.

Now, she’s thankful they got out when they did. It’s since been devastating to learn about neighbors who waited for an order to leave, she said, and barely got out — or didn’t.

“There was nothing telling us that we were in danger,“ said Espino.

But she said it also came as no surprise that the evacuation failure affected this section of Altadena, where a higher concentration of Black and brown families live, compared to the eastside. West Altadena had become an enclave for Black homeownership, partially an outcome of redlining and discrimination in surrounding areas, including eastern Altadena. It had also became home to a growing share of Latinos, like Espino and her family.

She said she grew up feeling like west Altadena and its residents were often overlooked or forgotten; this failure to issue timely evacuation alerts has only intensified that mistrust. Espino is now working with her displaced neighbors to recover, rebuild and prepare for future emergencies.

“I learned that we need to take care of our elder population — the community,” said Espino, now a neighborhood captain for the grassroots organization Altagether. “We’re going to put into place safety measures for ourselves.”

But for those who are seeking official answers, the next update on the investigation from the McChrystal Group isn’t due until late July. It’s not clear if the full after-action report will be complete then.

In a statement this week, the county’s Coordinated Joint Information Center, set up to respond to the fires, said that it has “answered numerous questions regarding our collective response” to the fires, but that it won’t speculate on the cause of the evacuation delays with incomplete information.

“McChrystal Group’s process is not only reviewing relevant information from first responders and emergency management professionals, but from members of the public who experienced the fires and the response first-hand,” the statement said.

Staff writers Terry Castleman and Rebecca Ellis contributed to this report.