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Lahaina Fire Investigation Report Released
On September 13, 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, was released by the Hawaiʻi Attorney Generalʻs office.
The report reveals that 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.
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.
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 and 140 recommendations to address these issues now. The report emphasizes the crucial role multiple entities, such as agencies, state, and county governments, should play in directly implementing these recommendations.
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, which impacted the ability to provide effective evacuation and firefighting operations during the wildfire event.
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.
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
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