An independent review commissioned by the Los Angeles County Board of Supervisors has revealed significant systemic failures in the county’s response to the catastrophic January wildfires, citing outdated policies, critical resource shortages, and communication vulnerabilities that hampered emergency alert and evacuation efforts. The report, compiled by the McChrystal Group, found that these weaknesses contributed to fatal delays for residents caught in the path of the Eaton and Palisades fires, which together claimed 31 lives and destroyed over 16,000 properties in areas including Altadena and Pacific Palisades.
Systemic Weaknesses Undermine Emergency Response
The comprehensive after-action review, released on September 25, 2025, did not identify a single point of failure but rather a “series of weaknesses” that strained the county’s emergency alert and evacuation capabilities to their limits. The report found that county policies and protocols surrounding evacuation warnings and orders were “outdated, unclear and contradictory,” failing to clearly delineate roles and responsibilities among various agencies. This led to inconsistent preparedness strategies and a lack of clear documentation and communication processes across the vast los angeles region.
First responders and incident commanders struggled to share real-time information due to unreliable cellular connectivity, inconsistent field reporting methods, and the use of various unconnected communication platforms. The extreme and rapidly moving fire conditions, particularly during the Eaton Fire which broke out at night, challenged the situational awareness of fire and law enforcement personnel, making it difficult to communicate the fire’s location to the public. This was exacerbated when wind conditions grounded aerial resources, including surveillance aircraft, almost immediately after the fire started.
Critical Staffing and Resource Shortages
The report highlighted significant resource constraints and staffing shortages that critically impacted the county’s ability to respond effectively. The Los Angeles County Office of Emergency Management (OEM) was described as “fundamentally inadequate for Los Angeles County’s complex emergency management needs,” operating with only 37 full-time staff members for its 10 million residents. For comparison, New York City, with a smaller population and geographic area, employs over 200 emergency managers.
Further deficiencies included a high number of sheriff’s deputy vacancies and a shortage of patrol vehicles. Aging infrastructure, such as a 38-year-old Computer Aided Dispatch (CAD) system, also presented challenges. These pre-existing deficiencies were magnified under the extreme conditions, turning what might have been manageable departmental challenges into limiting factors during the response and evacuation of over 250,000 residents.
Delayed Alerts and Communication Breakdowns
One of the most critical findings was the delay in issuing evacuation orders. In some neighborhoods of Altadena, where the Eaton Fire raged, evacuation orders were issued hours after incident commanders had recommended them, and long after homes had been destroyed. Interviews with survivors and data analysis revealed that some residents did not receive emergency alerts until their homes were already engulfed in flames.
Factors complicating the delivery of timely alerts included the mountainous geography, power outages that shut down cell towers, and heavy smoke that degraded signal strength. Many of the county’s alert systems, such as Alert Los Angeles County and Genasys PROTECT, require residents to opt-in to receive notifications, limiting their reach. There was also a gap in providing clear, stand-alone preparedness messaging to residents regarding extreme weather risks. The transition from an old alert system (CodeRED) to a new one (Genasys ALERT) also presented issues, with only four OEM staff members trained on the new system before the fires.
Acknowledging Heroism and Paving the Way Forward
While the report identified systemic failures, it also acknowledged the heroism of frontline responders. The McChrystal Group report stated that “frontline responders acted decisively and, in many cases, heroically, in the face of extraordinary conditions”. However, these events “underscored the need for clearer policies, stronger training, integrated tools, and improved public communication”.
The report lays out several recommendations for systemic improvements, emphasizing the need for clearer protocols, enhanced training, better integrated communication tools, and more robust public engagement. The Los Angeles County Board of Supervisors is scheduled to review the 133-page report and its recommendations in the coming week, with Supervisor Kathryn Barger pledging to turn the findings into action to better protect communities. The release of this independent news marks a crucial step towards accountability and strengthening the county’s resilience against future disasters in an increasingly challenging climate.
