During last year’s fires in the Los Angeles area, police dispatchers had to temporarily route 911 calls through a single captain’s personal cellphone. So many calls came in that some firefighter units went “dark” — meaning dispatchers were no longer tracking them. As communications broke down, some firefighters began to take their cues from captains they trusted instead of the agency’s top leaders.

These are just a few examples of emergency communications failures described in a new, comprehensive review of the deadly fires. The findings paint a picture of a response marred by poor preparation, communication issues and disorganized leadership that struggled to coordinate between jurisdictions.

The 724-page report, released Friday, comes from UL Research Institutes (ULRI), an organization that focuses on safety science. Gov. Gavin Newsom tasked the researchers with evaluating the conditions, decisions, actions and systems that influenced the conflagration. This is the second of two ULRI reports evaluating the fires.

Overall, the researchers found that Los Angeles authorities were not prepared or trained for such extreme conditions and that they struggled to work side by side as the situation deteriorated.

On the night the Eaton Fire took off, for example, “the speed and scale of the event overwhelmed the 911 system,” Derek Alconis, a senior research program manager and lead investigator at ULRI, said in a news briefing. “Calls came in faster than dispatch could manage or assign them.”

As the situation worsened, agencies struggled to communicate, and those in charge lost track of where crews were working and what they were doing.

“It was not an effective unified command,” Alconis said, adding that the confusion hampered evacuation efforts.

The report confirmed previous assessments of how the Palisades Fire started: LAFD did not fully mop up an earlier burn in the area. The department did not have standards for that kind of work, the report says.

The original burn, called the Lachman Fire, was the result of an alleged arson. The trial of the man accused of starting that fire ended in a mistrial this summer after the jury deadlocked. A second trial is scheduled for this fall.

In a statement, LAFD said it was carefully reviewing the analysis.

“While FSRI found that no single decision explains last January’s tragedy, that does not lessen LAFD’s responsibility for the decisions that were ours,” LAFD said. “The report identifies a number of areas where the LAFD must do better. They include how we confirm a fire is truly out before dangerous weather returns, how we track and direct every unit on a major fire, and how we plan and carry out evacuations with our partners. We accept those findings.”

The department said it had implemented a series of changes after its own review, including improving staffing procedures during dangerous fire weather and developing protocols to ensure fires are fully extinguished.

“This report holds the LAFD to a high standard, as it should,” the statement said. “We will carefully evaluate every recommendation that applies to us, continue to track our progress, and strengthen our ability to protect the communities we serve.”

The Los Angeles Police Department did not respond to a request for comment, and the Sheriff’s Department did not provide a response by the time of publication. A spokesperson for the Los Angeles County Fire Department said the agency could not comment because of pending litigation.

The fires, which started during a windstorm in January 2025, killed 31 people in the Pacific Palisades and Altadena communities. The blazes destroyed more than 16,250 homes and commercial buildings. Many residents still have not returned home and have struggled to clean up contamination left by smoke and debris. Frustration over the fire response and the rebuilding effort has become a heated election issue in the Los Angeles mayoral race.

The new report says, however, that the shortcomings it outlines did not drive the tragedy. Emergency responders were up against extreme fire behavior in windy conditions that made the homes themselves the fire’s fuel.

“The conditions in January 2025 were perfect for fire,” said Steve Kerber, a vice president at ULRI who leads its Fire Safety Research Institute. “The speed, scale and complexity of the Palisades and Eaton fires exceeded many of the capabilities of the systems designed to support suppression.”

Many of the 175 findings in the report will not come as a surprise to those who have followed the flurry of lawsuits, investigative news reports and city and county after-action reviews. But it offers a comprehensive picture of what went wrong, as well as something of a road map for the wind-driven urban firestorms that are growing more common across the West.

Among its 266 recommendations are to increase training opportunities for wildfire and incident management in California, to equip command staff with portable satellite internet kits in case of communication failures, and to train firefighters to use water from residential pools.

The report describes plenty of successes, as well. The authors said that the National Weather Service effectively communicated the extreme fire weather threat, and it credited a program of volunteers called Community Brigade with helping residents to evacuate. Private fire companies, too, helped save some structures and prevent fire spread, it says, though the report acknowledges that private firefighting is controversial.

ULRI also produced an after-action report about the 2023 Lahaina fires in Maui, an effort the authors said they were just finishing when the Palisades and Eaton fires took off. They immediately saw similarities between the events, in which fast-spreading, wind-driven fires overwhelmed fire departments.

To understand what went wrong in Los Angeles, the researchers behind the report evaluated in person more than 900 structures that burned and interviewed 200 residents and 295 people working at 22 agencies involved in the fire response. The team reviewed 911 calls, radio communications, dispatch data, evacuation maps, staffing plans and more.

However, many agencies, including LAFD and LAPD, did not provide records the report authors requested more than a year ago, they said, leaving key gaps in the assessment. For example, the authors said they did not get copies of emergency evacuation plans or records about the response to the Lachman Fire. And LAPD did not provide dispatch or radio communications or reports from officers and supervisors, they said.

Kerber said the L.A. area blazes demonstrated how fire safety no longer depends on the actions of a single homeowner or government agency.

“Risk increasingly operates at the neighborhood and regional level … future resilience depends on coordinated action across the entire system rather than on improvements made by one property owner or agency at a time,” he said.