During last year’s fires in the Los Angeles area, police dispatchers had to temporarily route 911 calls through a single captain’s personal cellphone. There were so many calls that some fire units became “in the dark,” meaning dispatchers were no longer tracking them. As communications were disrupted, some firefighters began taking cues from the captains they trusted rather than the agency’s top leaders.
These are just a few examples of emergency communications breakdowns outlined in a comprehensive new study of deadly fires. The findings paint a picture of a response marred by poor preparation, communication problems and disorganized leadership that struggled to coordinate across jurisdictions.
The 724-page report, released Friday, comes from the UL Research Institutes (ULRI), an organization that focuses on security science. Gov. Gavin Newsom tasked researchers with assessing the conditions, decisions, actions and systems that influenced the conflagration. This is the second of two ULRI reports assessing the fires.
Overall, the researchers found that Los Angeles authorities were not prepared or trained for such extreme conditions and struggled to work side by side as the situation deteriorated.
The night the Eaton Fire took off, for example, “the speed and scale of the event overwhelmed the 911 system,” Derek Alconis, senior research program director and principal investigator at ULRI, said during a press briefing. “Calls were coming in faster than the dispatcher could handle or assign them.”
As the situation worsened, agencies struggled to communicate and managers lost track of where teams were working and what they were doing.
“It was not an effective unified command,” Alconis said, adding that confusion hampered evacuation efforts.
The report confirmed previous assessments about how the Palisades fire started: The LAFD did not fully clean up an earlier fire in the area. The department did not have standards for this kind of work, the report said.
The initial fire, called the Lachman Fire, was the result of suspected arson. The trial of the man accused of starting the fire ended in a mistrial this summer after the jury deadlocked. A second trial is planned for this fall.
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In a statement, LAFD said it was carefully reviewing the analysis.
“Although the FSRI found that no single decision explains the tragedy of last January, this in no way diminishes the LAFD’s responsibility for the decisions we made,” the LAFD said. “The report identifies a number of areas where the LAFD needs to do better. They include how we confirm that a fire is actually out before dangerous weather conditions return, how we track and direct each unit in the event of a major fire, and how we plan and conduct evacuations with our partners. We accept these findings.”
The ministry said it implemented a series of changes after its own review, including improving staffing procedures in the event of a dangerous fire and developing protocols to ensure fires are completely extinguished.
“This report holds the LAFD to a high standard, as it should,” the statement said. “We will carefully evaluate each recommendation that applies to us, continue to monitor our progress, and strengthen our ability to protect the communities we serve.” »
The Los Angeles County Sheriff’s Office said it had not had time to review the report but was updating its 38-year-old dispatch system and hiring 80 new dispatchers. Since the fires, it has also equipped patrol vehicles with warning sirens for evacuations and strengthened its evacuation policy and training, the office said, while improving emergency communications and fire protection equipment, among other measures.
The Los Angeles Police Department did not respond to a request for comment. A spokesperson for the Los Angeles County Fire Department said it was implementing recommendations from other post-fire reviews, but had not had time to review the new recommendations in detail.
The fires, which broke out during a windstorm in January 2025, killed 31 people in the communities of Pacific Palisades and Altadena. The fires destroyed more than 16,250 homes and commercial buildings. Many residents still have not returned home and are struggling to clean up contamination left by smoke and debris. Frustration over the fire response and rebuilding efforts has become a hot election issue in the Los Angeles mayoral race.
The new report, however, asserts that the shortcomings it highlights were not the cause of this tragedy. Rescuers faced extreme fire behavior in windy conditions that made the homes themselves fuel for the fire.
“Conditions in January 2025 were perfect for a fire,” said Steve Kerber, a ULRI vice president who heads its fire safety research institute. “The speed, scale and complexity of the Palisades and Eaton fires exceeded many of the capabilities of the systems designed to support suppression.”
Many of the report’s 175 findings will come as no surprise to those who have followed the wave of lawsuits, investigative reporting and after-action reviews of cities and counties. But it offers a complete picture of what went wrong, as well as a sort of road map for wind-driven urban firestorms, which are increasingly common in the West.
Among its 266 recommendations are increasing wildfire and incident management training opportunities in California, equipping command staff with portable satellite internet kits in case of communications outages, and training firefighters to use water from residential swimming pools.
The report also describes many successes. The authors said the National Weather Service effectively communicated the extreme fire threat and credited a volunteer program called Community Brigade with helping residents evacuate. Private fire companies also helped save some structures and prevent fires from spreading, the report said, although the report acknowledged that fighting private fires is controversial.
ULRI also produced an after-action report on the 2023 Lahaina fires on Maui, an effort the authors said they had just completed when the Palisades and Eaton fires took off. They immediately saw similarities between the events, in which fast-spreading, wind-driven fires overwhelmed fire departments.
To understand what went wrong in Los Angeles, the researchers behind the report assessed in person more than 900 structures that burned and interviewed 200 residents and 295 people working at 22 agencies involved in fighting fires. The team reviewed 911 calls, radio communications, dispatch data, evacuation maps, staffing plans and more.
However, many agencies, including the LAFD and LAPD, failed to provide documents requested by the report’s authors more than a year ago, they said, leaving significant gaps in the assessment. For example, the authors said they did not obtain copies of emergency evacuation plans or records on the response to the Lachman fire. And the LAPD provided no dispatch, radio communications or reports from officers and supervisors, they said.
Kerber said the fires in the Los Angeles area demonstrated how fire safety no longer depends on the actions of a single homeowner or government agency.
“Risk increasingly operates at the neighborhood and regional level…future resilience depends on coordinated action across the entire system rather than improvements made by one property owner or agency at a time,” he said.
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