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After disaster declarations, California mandates timely reports. More than 100 are now years overdue
On a fall morning 34 years ago, a fire, rekindled and supercharged by Diablo winds, began its assault on the East Bay hills. Many times since, Californians have lived through similar disasters.
The fire then was fueled by brush — desiccated by both long-term drought and days of 90-degree heat during the peak of California’s fire season. Powerful winds cast embers wide, setting shake roofs alight throughout hilly, narrow neighborhood streets.
First responders were overwhelmed.
Water pressure fell as service lines ruptured and homes burned.
Communication between departments — including those that rushed into the area to offer mutual aid — was disorganized, with at least one unit waiting 24 hours for orders, while others freelanced, doing what they thought was best. A lack of common radio frequencies delayed evacuations.
Those who went to the emergency operations center were “greeted by pandemonium,” according to an after-action report released by the California Governor’s Office of Emergency Services, known as Cal OES.
Just days after the Oakland Hills fire began on Oct. 20, 1991, the flames were under control. But 25 people were dead, 150 were injured and more than 3,000 homes were destroyed, making it one of the costliest disasters in U.S. history at the time.
Things had gone so poorly that California’s legislators recognized change was needed.
By 1993, they enacted a law to overhaul how the state manages disasters, including how emergency responders coordinated their work and how they disseminated lessons learned. One provision of the law mandates that Cal OES “complete an after-action report within 180 days after each declared disaster.” (The original legislation said 120 days; lawmakers changed it to 180 in 2022.)
What is an after-action report?
After-action reports offer comprehensive reviews of disaster incidents, and many agencies write them after emergencies. They include which parts of the response went well and which need to be improved.
For example, after-action reports released by the L.A. Fire Department and Los Angeles County after January 2025’s fires, have shown that understaffing hampered the initial response, that evacuation orders were delayed and that communication was often fragmented and ineffective. Comparing reports can also reveal perennial problems, as LAist found when analyzing the after-action reports about the 2018 Woolsey Fire and the Eaton Fire.
The goal was to make sure that emergency departments across the state could learn from thorough recountings of past crises, avoid repeating mistakes and save lives in the process.
However, compliance has been a mess.
Since 2017, Cal OES has completed only six after-action reports, a fraction of the more than 100 that need to be completed following disaster proclamations by California governors. Eighteen are listed by the agency as in process.
It’s been more than 2,900 days since the 2017 Thomas Fire — one of California’s most destructive fires — was contained. Cal OES has yet to release its report.
Many other reports have been similarly delayed.
Assemblymember Rhodesia Ransom, a Stockton Democrat who heads the Assembly Committee on Emergency Management, pointed out that the report on the 2018 Camp Fire in Northern California “was not published until 10 months after the L.A. wildfires started.”
“Emergency response is a rapidly changing landscape,” Ransom said, “and when reports take years to become public, we leave potential solutions on the table and risk those lessons becoming outdated.”
Cal OES told LAist that it remains committed to streamlining its processes while upholding rigorous standards.
“For every incident that receives a Governor’s State of Emergency proclamation, Cal OES conducts a thorough after-action review,” a Cal OES spokesperson wrote in a statement. “Given the scale, complexity, and number of after-action reviews, completion timelines can vary to ensure completeness and meaningful analysis.”
'Cal OES has never completed after-action reports on time'
In 2019, the California State Auditor’s Office released a deep dive into Cal OES’s history of delayed after-action reports, finding that out of 65 emergency proclamations issued from 2014 to 2018, just eight reports had been completed.
According to the audit, “the project manager responsible for improving after-action reporting at Cal OES shared with Cal OES’s advisory board and its director that Cal OES has never completed after-action reports on time.”
The audit — titled “California Is Not Adequately Prepared to Protect Its Most Vulnerable Residents From Natural Disasters” — references mistakes made during the Sonoma Complex and Thomas fires in 2017.
It points out that crucial evacuation messages during the Sonoma and Thomas fires were sent only in English, even though many people in those areas lacked proficiency in the language. But, the audit argues, if Cal OES had published its reports in a more timely manner, that could have influenced Butte County to make changes to its emergency preparations. A year after those 2017 fires, the Camp Fire killed 85 people in Butte County. During that fire, the county sent alerts only in English.
“The potential value that one jurisdiction could gain from learning about another’s errors during emergency planning or response makes Cal OES’s failure to complete timely after-action reports a serious concern,” the audit states.
Why the delays?
The audit scrutinizes three factors that contribute to Cal OES’s delays:
- Non-cooperation from local agencies
- Lack of staff to research and write the reports
- A lack of clarity about when the clock starts on 180 days
Cal OES makes the case to the auditor that local jurisdictions are often delayed in sharing information, if they share it at all. That’s a problem, as state after-action reports rely on local agencies providing details about their emergency response.
The auditor questions Cal OES’s decision to delay the reports for that reason, given the benefits of sharing information quickly. It's unclear if this issue has been resolved since the audit was written.
Another reason cited for the delays was a lack of resources.
In response to the audit, then-Cal OES Director Mark Ghilarducci acknowledged that the agency had not completed after-action reports in a timely manner and that there was an ever-growing backlog. He cited personnel constraints, and said that the same staffers responsible for the reports were also working on the disasters themselves.
“As disasters increase in scale, complexity and frequency, there are more AARs [after-action reports] to complete, yet fewer staff to complete them,” Ghilarducci wrote.
However, he said, even if an after-action report hasn’t been filed, Cal OES engages in dialogue with local jurisdictions during and after a disaster.
The auditor’s office replied: “These discussions are a poor substitute for the broader and more complete perspective that after-action reports are intended to provide.”
Cal OES has increased staffing levels since the audit was published in 2019, according to Heather Gonzalez and Drew Soderborg, analysts with California’s Legislative Analyst’s Office. They told LAist that it’s unclear whether that increase has improved the agency’s ability to write after-action reports.
Finally, in the audit, Cal OES mentions a lack of clarity around when the 180-day period specified in California law begins. The agency operates as though the clock starts when a disaster has wrapped. But that moment can be unclear — or even nonexistent.
Which may be why the state has waited a decade for an after-action report about tree mortality. That emergency declaration was signed in 2015 by then-Gov. Jerry Brown, who left office in January 2019. According to official records, that emergency is ongoing, as are many others, years after being initiated.
The audit also notes that Cal OES officials have discussed the need for a firm definition of when to start the 180-day clock.
“Given that the law requiring Cal OES to complete these reports became effective in January 1993,” the auditor wrote, “... we question the urgency of its efforts to produce those reports in a timely manner.”
Ransom, the Assembly member from Stockton, pointed out that the disaster declarations for the Eaton and Palisades fires also remain open. She said she is developing legislation to improve the after-action report process.
“We need to be proactive about ensuring California is better equipped for the next disaster, " Ransom said. “We are determined to get reports out faster and ensure accountability moving forward.”