Report Acknowledges Actions of First Responders and Calls for Urgent Change by State and County Governments to Create a Safer Hawai?i

HONOLULU - Hawai?i 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:

1. Perception of Risk and Preparedness

The low perception of wildfire risk is not aligned with the growing wildfire threat in Hawai?i, 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.

1. 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.

1. 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 Hawai?i 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 Hawai?i is safer and has a more sustainable future for residents and visitors.”