On Friday, September 13, 2024, Hawaiʻi Attorney General Anne Lopez announced the results of the Lahaina Fire Incident Analysis Report, the second report of the three-part evidence-based investigation into how state and county governments responded during the Maui wildfires.
The report revealed that a complex set of factors including weather and its impacts, risk and preparedness, decades-old infrastructure, organizational structure, and incident management and coordination created a historic disaster. The report was prepared by the Fire Safety Research Institute (FSRI), a part of UL Research Institutes.
wake-up call
“This investigation serves as a wake-up call for the state and county governments to learn from the past and urgently prepare for the future,” says Attorney General Lopez.
“It is also a testament to the courage of our emergency services personnel and the everyday heroes who helped thousands of Lahaina residents and visitors to reach safety.” This was the most deadly fire in North America in 100 years.
third-party FSRI
FSRI has extensive experience researching fire dynamics, structure-to-structure fire spread
In August 2023, Attorney General Lopez selected the independent, third-party FSRI to assess the performance of state and county agencies in preparing for and responding to the Maui wildfires.
FSRI has extensive experience researching fire dynamics, structure-to-structure fire spread, and near-miss firefighting incidents.
wildfire preparedness
“The wildfire preparedness, prevention, and operational measures in place that day faced significant—sometimes unprecedented—challenges as the threat escalated. Insufficient resources and investment across multiple domains hindered the development of a unified fire management strategy and impacted prevention, preparedness, and response,” said Steve Kerber, Ph.D., PE, vice president and executive director of FSRI.
“The report concludes the devastation caused by the Lahaina fire cannot be connected to one specific organization, individual, action, or event,” added Kerber. “The conditions that made this tragedy possible were years in the making.”
systems-analysis methodology
The report emphasizes the crucial role multiple entities should play in directly implementing these recommendations
For this research, FSRI used a systems-analysis methodology to evaluate the complex intersections between environmental conditions, human activity, established policies and procedures, organizational structures, and accepted norms and perceptions.
FSRI made 84 findings with 140 recommendations to address these issues. The report emphasizes the crucial role multiple entities such as agencies, and state and county governments should play in directly implementing these recommendations.
Phase Two report findings
The Phase Two report identified three areas that need immediate attention:
- Perception of Risk and Preparedness
The low perception of wildfire risk is not aligned with the growing wildfire threat in Hawaiʻi, which led to a widespread lack of preparedness among county, state, and privately owned entities and residents. This also includes systemic issues tied to years of decisions that have led to underinvestment in wildfire prevention and mitigation policies, public education, and organizational structure. - Infrastructure Standards
Decades-old infrastructure standards, including community planning, codes and standards, public utilities, and vegetation management, were key contributors to the widespread fire destruction in Lahaina. Lahaina’s dense urban layout turned tragic as the fire’s initial impact hit the most populated area, rapidly spreading through closely packed structures and creating severe evacuation obstacles. - Incident Management and Coordination
First responders heroically saved many lives, placing themselves in extreme danger between the unpredictable fire fronts and vulnerable residents. The Maui County incident management operations, however, consisted of a siloed command structure that contributed to a lack of communication both to the public and responding agencies. The lack of pre-event planning, unified incident command, and operational coordination with assisting and cooperating agencies resulted in insufficient communications that impacted the ability to provide effective evacuation and firefighting operations during the wildfire event.
analysis with recommendations
The focus of the Phase One Lahaina Fire Comprehensive Report and timeline was to identify the facts
“Our Phase Two report shows that Lahaina lacked the level of cohesive fire prevention, preparedness, management strategy, resources, and investment that are necessary to protect the population from an extreme wildfire event,” added Kerber.
The focus of the Phase One Lahaina Fire Comprehensive Report and timeline was to identify the facts; the Phase Two Lahaina Fire Incident Analysis Report is the scientific analysis with recommendations that can be implemented more quickly; and Phase Three will focus on broader systemic recommendations for the future.
comprehensive database
Attorney General Lopez also announced the comprehensive database of documents and media obtained during the investigation is publicly available.
It contains approximately 850 gigabytes of video files, audio files, photographs, and documents relating to the August 8, 2023, Maui fires obtained by the Department and FSRI in connection with this investigation. Among other files, this database contains:
- Maui Police Department (MPD) body camera footage and other videos of the fire event;
- 911 dispatch audio files;
- Vehicle location data for MPD and Maui Fire Department vehicles during the fire event;
- Notes, sign-in sheets, photographs, and other documents created within the Maui Emergency Operations Center (EOC) on August 8, 2023, and afterward;
- FSRI damage assessment videos and images;
- Audio recordings of interviews conducted by FSRI with dozens of state and county officials; and
- All manner of documents from state, county, and federal agencies.
investigation transparency
Access to this database is being provided as a public service by the Department of the Attorney General at no charge so all of the people of Hawaiʻi may learn directly from the source documents regarding this tragedy.
“From the outset, our commitment to transparency in this investigation has been of crucial importance, and the release of this database honors our continuing commitment,” said Attorney General Lopez.
science-based recommendations
“We are not here to place blame. It is clear from the Phase Two analysis that we need to make significant changes at the county and state level and involve a broad range of individuals and organizations, to ensure we are better prepared for future wildfires that are not only possible but increasingly likely,” added Attorney General Lopez.
“Good governance requires we take these science-based recommendations seriously and work together to implement changes in our processes and protocols to save lives and property and ensure Hawaiʻi is safer and has a more sustainable future for residents and visitors.”
