Fire Safety Research Institute report: No single cause identified for deadly Lahaina wildfire

The Lahaina wildfire that killed at least 102 people and destroyed more than 2,000 buildings did not stem from a single cause, according to the phase-two Lahaina Fire Incident Analysis Report released Friday and prepared by the independent Fire Safety Research Institute for the state of Hawaiʻi.

Instead, the conflagration was the result of “a complex set of factors including weather and its impacts, risk and preparedness, decades-old infrastructure, organizational structure and incident management and coordination,” an announcement from the Department of the Attorney General said.

“The report concludes the devastation caused by the Lahaina fire cannot be connected to one specific organization, individual, action or event,” said Steve Kerber, Ph.D., PE, vice president and executive director of FSRI. “The conditions that made this tragedy possible were years in the making.” 

Attorney General Anne Lopez said: “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. 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.”

The phase-two report follows and builds upon the phase-one fact finding report released in April. That first report included a comprehensive timeline of the Aug. 8-9, 2023, Lahaina wildfire. The evidence-based investigation is aimed at assessing how state and county governments responded to the Maui wildfires. Phase two focuses on the complex factors that led to the fire, and it includes recommendations that can be implemented immediately.

During a news conference this morning, Derek Alkonis, FSRI research program manager, said the wildfire threat in the state of Hawaiʻi is “very real,” and it’s time to “step it up, to put more effort in that area.”

Lopez added that there have been more than 1,500 wildfire ignitions that have required an emergency response since Aug. 8, 2023. Of those fires, seven burned more than 500 acres, she said.

“So I think the risk is real and it’s a present danger, and climate change will only continue to make things worse,” she said.

Lopez said the state administration is “committed to ensuring that we don’t sit on these recommendations, that we learn from the past, and that we move forward in a collaborative manner with county agencies, with other organizations and individuals to ensure that we create a safer Hawaiʻi.”

In a news release, Lopez said: “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.”

One of the phase-two report findings is of low 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,” the AG news release says. “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.”

Another finding focuses on outdated infrastructure.

“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,” the news release says.

Another key finding was on incident management and coordination.

“First responders heroically saved many lives, placing themselves in extreme danger between the unpredictable fire fronts and vulnerable residents,” the news release says. “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,” Kerber said. 

The County of Maui continues to stand in steadfast support of the firefighters, police officers, emergency response personnel, and its residents who heroically sacrificed their personal safety to assist our community. We continue to regard their efforts in August 2023—to suppress four (4) simultaneous fires amidst extreme weather conditions across both wildland and urban conditions—as the highest form of service to our people.

“The County remains committed to a transparent and thorough investigation that will help us identify and implement best practices—many that have already been established to protect the health and safety of our community,” said Mayor Bissen.  “This investigation, paired with the finding of our County Police, Fire and MEMA After Action Reports, will be leveraged to enhance our ability to respond to future disasters and save lives.”

This afternoon, Maui County acknowledged the “Department of the Attorney General’s efforts with respect to this report and aligns with its vision of transparency and disclosure.”

“The large majority of information used in this report came from the County and its hard-working and resilient public servants,” the County statement says. “To date, the County has delivered to the state over 50 separate productions of documents (containing over 23,000 distinct files, including approximately 8,000 video and audio files; more than 85,000 pages; and approximately 125 GB of data) and has made its personnel, directors, deputies and employees available for over 150 technical interviews and numerous site visits into and around the affected areas. Technical interviews continue to this day, with another scheduled for next week.”

According to the County, the technical interviews were compelled by the Attorney General’s investigatory powers, “and the interviewees were not offered immunity from subsequent civil or criminal prosecution in exchange for their testimony. The interviewees were not notified that their recorded interviews would be released by FSRI as part of a public media presentation.” 

The County said information provided and access to current and former personnel for interviews was done “while simultaneously defending over 700 civil lawsuits and engaging in global settlement mediation.”

“Given the efforts by all parties in the lawsuits, the County is focused to accelerate the delivery of important relief for the victims of these tragic fires with achieving a global settlement,” the County said. “The County remains committed to the ongoing efforts to resolve all claims and disputes to facilitate the path for further healing and recovery by our Maui community.”

This morning, before releasing an official statement, Maui County officials questioned how the report could be comprehensive if FSRI did not investigate the acts and omissions of Hawaiian Electric Co., Kamehameha Schools, Spectrum and Hawaiian Tel.

Toni Schwartz, public information officer for the Department of the Attorney General, said via text message that FSRI did speak to HECO and others, but “it was done to analyze the cooperation with county and state employees.”

“Our scope was to analyze state and county response to the incident,” Schwartz said. “Investigating outside entities was not part of the scope.”

In August 2023, Lopez selected the independent, third-party FSRI, part of the UL Research Institutes, 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,” Kerber said. “Insufficient resources and investment across multiple domains hindered the development of a unified fire management strategy and impacted prevention, preparedness and response.”

Regarding preparedness, one of the phase-two report findings is that the Maui Fire and Police Departments did not initiate an after-action report for the 2018 Hurricane Lane wildfire that posed a significant threat to Lahaina town. The Maui Emergency Management Agency did not finalize an after-action report for that wildfire.

The report’s recommendation says: “MEMA, the MFD and the MPD should create policies that include incident parameters requiring an (after-action report) to ensure learnings are documented and changes required for improvement are implemented.”

The report also says that, prior to the Lahaina afternoon fire on Aug. 8, 2023, outdoor warning sirens had never been used for warning of wildland-urban interface fires.

“During (technical discussions) with MEMA and Hawaiʻi Emergency Management Agency members, they stated that activation of the siren system was not discussed during August 8, 2023,” the report says.

On that date, there were five sirens located off of Honoapiʻilani Highway in the area of the Lahaina afternoon fire that wreaked devastation on Lahaina town. According to reports by both Maui and Hawaiʻi emergency management agencies, only two sirens were operable at the time of the fire.

Wildland-urban interfaces refer to the area where human development and undeveloped wildland meet. Such areas are vulnerable to human-caused wildfire ignition and rapid fire spread.

“Human-caused ignitions, large swaths of unmanaged fire-prone vegetation, and community design and infrastructure that are not adapted to the high level of wildfire threat are unmitigated statewide issues,” the report says.

For its 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 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.

Schwartz said the goal is to have the phase-three report released to the public by the end of this year, although that depends on responsiveness to requests for information.

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 Aug. 8, 2023 Maui fires obtained by the Department and FSRI in connection with this investigation. Among other files, this database contains:

• Maui Police Department 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 on Aug. 8, 2023, and afterward.
• FSRI damage assessment videos and images.
• Audio recordings of interviews conducted by FSRI with dozens of state and county officials.
• All manner of documents from state, county and federal agencies.

Access to this database is being provided free as a public service by the Department of the Attorney General “so all of the people of Hawaiʻi may learn directly from the source documents regarding this tragedy,” the department’s news release says.

“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,” Lopez said.

“We are not here to place blame,” she said. “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. 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.”

Editor’s note: This report is updated from an earlier posted version. It includes an official statement from Maui County in response to the Fire Safety Research Institute phase-two report.