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Untangling the mystery of failed Altadena evacuations: ‘There should have been all sorts of red lights’

Empty hospital beds on a deserted street at night.
Hospital beds are abandoned in Altadena after patients were evacuated from Two Palms Nursing Center during the Eaton fire on Jan. 8.
(Gina Ferazzi / Los Angeles Times)

When flames bellowed up out of Eaton Canyon on the evening of Jan. 7, west Altadena did not, at first glance, seem to pose the most urgent challenge for evacuations.

The area was about 2? miles from the fire’s ignition point. Unlike Pacific Palisades, a community built on the steep bluffs and canyons of the Santa Monica foothills with narrow — and limited — roads in and out, west Altadena presented few glaring topographical hurdles. The bulk of homes were in the flatlands, built on a grid with multiple escape routes.

Yet 17 people died in west Altadena, and many residents told harrowing tales of just barely escaping as flames converged around their homes, down their blocks.

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What went wrong with L.A. county’s warnings and evacuations is now the subject of two different investigations after Times reporting found that emergency wireless alerts went out to west Altadena almost five hours after fire began to engulf homes in the neighborhood. In some areas, it took even longer.

Los Angeles Fire Chief Kristin Crowley said that the fire department has deployed all available resources and positioned fire patrols and engines in high-risk areas across Los Angeles.

Experts in emergency management said the struggle to coordinate evacuations is puzzling given the time and geography. But they also stressed that fast-moving fires in urban areas can be incredibly challenging and that we do not know enough yet to jump to conclusions about tactics.

Some law enforcement officers were spotted driving through west-side neighborhoods around 2 a.m. — before the formal alerts were issued — with loudspeakers telling residents to leave, but at that point, it appeared they did not have enough manpower to facilitate all necessary evacuations.

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For some experts, the delay in wireless evacuation orders in west Altadena — and the ensuing lack of an explanation to the public — is confounding.

“There should have been all sorts of red lights on the dashboard for west Altadena, based on what was happening on the ground and the timeline of reports about fire in the neighborhood,” said Thomas Cova, a professor of geography at the University of Utah in Salt Lake City, who specializes in emergency alerts during wildfires. “Why were the boots on the ground warning people before the people in the office, whose job it is to warn them? That’s upside down.”

More than five weeks after the blaze swept through Altadena, officials have yet to explain why nine hours passed between the outbreak of the fire in Eaton Canyon just after 6 p.m. and the first wireless cellphone alert issued to the west side of Altadena.

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In this section of western Altadena, residents weren’t ordered to evacuate until after 5 a.m., according to records reviewed by The Times. That was well after smoke and flames were threatening the area.

The problem does not seem to be technical: A large swath of Altadena’s east side received multiple electronic evacuation orders, starting at 7:26 p.m, while those on the west side did not get orders until 3:25 a.m — well after the first radio reports of fire in west Altadena came in at 10:51 p.m.

For residents, Cova said, it can be frustrating when officials take so long to explain what went wrong.

“This is not that complicated,” Cova said. “There’s somebody who’s supposed to do this — and we know they did it for eastern Altadena, so it’s not like a technical malfunction. ... The person knew how to use the system. They had already used the system a few hours before. Why didn’t they continue to use it?”

But Kevin McGowan, director of L.A. County’s Office of Emergency Management which sends out the wireless alerts, said there is not a simple answer.

“I don’t want to get into the details,” McGowan told The Times earlier this week. “I think there’s a lot to unpack between what is being reported by news organizations, what is understood within the different structures — both evacuations and alerts and warnings.”

With thousands of lives at risk, a mobile command post tasked with issuing evacuation orders struggled to keep pace with the Eaton fire’s rapid progress.

McGowan characterized The Times’ reporting on the delayed alerts in west Altadena as an issue beyond just the alerts. “It’s evacuations in totality,” he said. He declined to elaborate further, citing the ongoing investigations.

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For national emergency scholars like Cova, it is startling to see Los Angeles — home to some of the nation’s most experienced and highly trained emergency responders — struggle to issue timely emergency alerts and evacuate residents.

“They’re responsible for overseeing millions of people and have dealt with many fires,” Cova said. “They have a lot of resources, maybe the most. I mean, how much wealthier can you get than L.A. County? Not much. They have all the training. … they have the rock stars of emergency management, in fire, police and the EOC.”

L.A. County Sheriff Robert Luna — whose agency played a key part in coordinating evacuations the night of Jan. 7 but was not responsible for sending wireless alerts — said conditions during the height of the Eaton fire were particularly challenging. Not only were deputies facing strong winds pushing large, flying embers that were erratically shifting the fire, they were doing so in the dark.

“It was complete chaos that night,” Luna said in an interview with The Times. “There was no electricity, it was in the middle of the night or the middle of the morning — not only is it pitch dark, but the smoke was so thick you couldn’t see two houses ahead of you.”

Dark evacuations are always harder, Luna said, because every neighborhood is different. Deputies have to make sure they don’t miss backyard ADUs or any apartments in a multiunit buildings, not to mention help with vulnerable residents in senior homes.

“There were deputies who said they were disoriented,” he added. “This fire was crazy, this was literally a hurricane of flames without water.”

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Typically in a major fire, sheriff’s officials work in step with fire and county Office of Emergency Management officials on evacuations, but Luna said fire personnel take the lead because they are tracking fire behavior, the blaze’s movement and associated weather.

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

Once a decision is made to evacuate an area, Luna said, there’s a two-layered process: OEM sends out the electronic alert and deputies in the field are alerted to begin making sure the order is carried out.

“Our deputies are literally going down the streets, they’re on public address systems, they are getting out of their cars, they’re knocking on doors,” he said. “They’re doing everything they can to alert the public that they need to go.”

But they also don’t have to wait for that order to be formally issued.

Los Angeles County sheriff’s deputies found two elderly women still at a west Altadena senior home hours after the Eaton fire threatened the area and well after evacuations had been ordered.

“If they’re in the field and they see something burning … they’re taught to take action,” Luna said. “The deputies have discretion as they’re making evacuations. If they see another neighborhood or another block burning that’s outside of their area, they’re going to do everything they can to try and prioritize life ... and that’s what happened this night.”

Some residents told The Times that some deputies were seen trying to to evacuate parts of western Altadena around 2 a.m. — before the area’s first evacuation order was issued — but it’s unclear how widespread those efforts were. Many west Altadena residents said that when they ended up evacuating, they didn’t see any emergency officials or sirens nearby.

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Luna declined to comment on specific timing, location or manpower issues in the Eaton fire evacuations, choosing to wait for the ongoing after-action review. But he said that when deputies decide on the ground to begin evacuations due to dangerous conditions, it would be standard procedure for them to call in the situation to the fire’s unified command. He declined to say if that happened in this specific circumstance.

However, Luna did say he is not yet aware of any Sheriff’s Department missteps or issues from the first 12 hours of the Eaton fire.

L.A. County Deputy Fire Chief Al Yanagisawa, who became one of the lead incident commanders for the Eaton fire at about 10:30 p.m. on Jan. 7 and remained in that post for the next 42 hours, said the Eaton blaze was the worst he had seen in his 24-year career.

“The most destruction, chaos,” Yanagisawa said. “Difficult decisions.”

While Yanagisawa was not on the team that determined where evacuation alerts were needed or the team sending them out, he said that process was a team effort between L.A. County Fire, the Sheriff’s Department and the OEM.

“We recommend [evacuation alerts] to law enforcement by standing next to each other at the command post and saying, ‘Look, this is what the fire’s doing, this is where it’s projected to go, we need to get these people out,’” he said.

Yanagisawa said there was a clear division — and coordination — of responsibilities. The operations team in charge uses paper and digital maps to continuously draw out the fire’s movement and evacuation zones. Then, it reports that back to a representative from the OEM, either in-person or over dispatch, and the OEM sends out any wireless alert and updates the county’s online notification system, operated by Genasys.

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He declined to comment on why alerts appeared to have been delayed in west Altadena.

Mark Ghilarducci, the former director of the California Governor’s Office of Emergency Services who developed the state’s 2019 Alert and Warning Guidelines, said there are many ways in which evacuations and sending of timely and accurate alerts can be hampered during erratic, fast-moving wildfires.

Sometimes officials are reluctant to alert too many people. Other times they do not coordinate quickly enough and get overtaken by a rapidly changing firestorm. They could also be stymied by technological failures such as power outages and disrupted cellphone signals.

Some west Altadena residents said they lost cellphone service and power on the night of Jan. 7. However, in this case, that doesn’t mean emergency responders sent alerts that didn’t get through: If officials sent out alerts, they would still show up in the PBS WARN database, which they do not.

But cellphone outages indicate that west Altadena evacuation failures did not hinge entirely on officials’ failure to send wireless alerts; even if they had tried to send evacuation orders, some or many residents would not have received them.

“The public, they’re basically use these cellphones for everything now, and we’re pushing data and information over these systems, but it’s only as good as the system that supports it,” Ghilarducci said, noting that lawmakers have pushed cellphone companies to have backup power for towers in high risk fire areas.

While it is tempting to think a single person made a mistake or forgot to push an alert, Ghilarducci stressed that alerts involve coordination from multiple emergency managers and responders.

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“It does take a team to do this,” Ghilarducci said. “It’s not like one person sitting in a closet who makes the decision they’re going to issue an alert.”’

While Ghilarducci stressed he did not know how commanders made decisions during the Eaton fire, he said he could imagine a scenario where commanders were looking at polygons about where fire is going to move and then quickly had to pivot as new fires erupted.

“Things are changing by the second. And I think that — I don’t know this for sure — what will end up coming out in the after-action report is that the conditions were such that maybe situational awareness was lost on the part of what areas were impacted and what areas weren’t impacted. Things were moving so rapidly that that area got missed.”

The son of 100-year-old Jean Bruce Poole, who was left behind at an Altadena senior home during Eaton fire evacuations, said the facility failed his mother.

A key lesson from the Eaton fire and other powerful and erratic fires that have swept through California in the last decade, Ghilarducci said, is that officials should act more swiftly to alert and evacuate.

“We’re erring more on the side of do it sooner rather than later to take into account these extreme events,” Ghilarducci said. “But we’re still learning in this particular area, and there’s more to do, more training to be done.”

Over the last month, Luna said, he’s continued to hear stories of “absolutely heroic work” from his deputies in unprecedented conditions, but many have also expressed guilt about the 17 lives lost. One is always too many.

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“They wanted to believe they saved everybody,” he said of conversations with deputies who were out that night.

Luna said he looks forward to the after-action report.

“If something comes up that’s absolutely legitimate,” he said, “we’ll learn from it so we can get better.”

Times staff writer Summer Lin contributed to this report.

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