Hawaiʻi Attorney General Anne Lopez Announces Results of Lahaina Fire Investigation Analysis: No Single Factor, But Complex Interaction of Factors, Led to Maui Fire Devastation
September 13 2024 - 3:53PM
Hawaiʻi Attorney General Anne Lopez announced today 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 reveals
no single factor led to the devastation. Instead, 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.
“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.
The Phase Two analysis, informed by the April 17, 2023, Lahaina
Fire Comprehensive Phase One Report facts and timeline, identifies
the complex set of factors that led to the devastation and includes
recommendations that can be implemented immediately.
“Responsible governance requires us to seek answers and better
understand how state and county governments responded, and how we
can best make efforts to prevent disasters of this magnitude from
happening again,” says Attorney General Lopez.
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.
“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.”
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
now. The report emphasizes the crucial role multiple entities such
as agencies, state and county government should play in directly
implementing these recommendations.
The Phase Two report identified three areas that need immediate
attention:
- Perception of Risk and PreparednessThe 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.
“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.
Attorney General Lopez also announced the comprehensive database
of documents and media obtained during the investigation is now
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.
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.
“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.”
Media Contacts:
Dave Day
Special Assistant to the Attorney General
Office: 808-586-1284
Email: david.d.day@hawaii.gov
Web: http://ag.hawaii.gov
Toni Schwartz
Public Information Officer
Hawai‘i Department of the Attorney General
Office: 808-586-1252
Cell: 808-379-9249
Email: Toni.E.Schwartz@hawaii.gov
Web: http://ag.hawaii.gov
Fire Safety Research Institute
Email: ULFSRI@allisonworldwide.com