Barry Biermann, the fire chief in California’s Napa County, wasn’t scheduled to work until Monday morning, but he decided to head in Sunday, Oct. 8, just in case.

He knew that conditions in Napa’s wine country, known for its Mediterranean climate and valleys of vineyards, were ripe for a fire: There was a high wind advisory, it was an unusually warm day, and there was plenty of dried-out brush and grass that late in the year.

By the time Biermann got into work, many of his fire crews already were tied up at small blazes. So when a call came in just before 10 p.m. reporting a fire in a neighborhood above the Silverado Country Club, Biermann decided to head up to Atlas Peak.

He quickly recognized that the Atlas Peak blaze was no small brush fire – residents already could be trapped – so he called the California Department of Forestry and Fire Protection, or CAL FIRE, for help: He wanted 50 engines, 12 bulldozers and 16 hand crews.

But Biermann soon learned he wasn’t the only fire chief asking for help. This fire wasn’t even the biggest threat CAL FIRE was facing that night – another blaze had started about 30 miles north.

“Someone came up on the radio and said, ‘Hey, did you hear that?’ And I said, ‘No, what?’ And they said, ‘Within two hours, that fire that started in Calistoga’s going to be in the city of Santa Rosa.’ And I was like, ‘My gosh,’ ” he said.

Those blazes – the Atlas Peak and Tubbs fires – were two of dozens that would break out Oct. 8, ultimately killing 44 people and damaging or destroying 21,000 homes.

A five-month KQED investigation of what happened that first night of the fires found a series of failures and missteps by both local and state officials that go well beyond previously documented evacuation delays: Our review of thousands of 911 and dispatch calls, along with dozens of interviews, reveals large systemic problems with the state’s emergency response procedures.

The review shows that even with homes burning and lives on the line, first responders and decision-makers remained hamstrung by those problematic procedures and policies. They struggled to adapt as quickly as the fires were moving.

Among our findings:

Electrical problems sucked resources and delayed emergency response: The fires started early; many were caused by downed power lines, which overwhelmed the electrical grid and lit new blazes. These electrical problems sucked firefighting resources to smaller blazes, leaving first responders short-staffed when the larger fires broke out later. The power issues also delayed fire crews, which had to wait for utility workers to power down live lines.

Communication among first responders broke down: Inconsistencies in the technology and terminology used by different jurisdictions to tell people to evacuate caused confusion and delayed alerts to the public.

911 centers were overwhelmed: 911 operators were juggling dozens of calls at once and often unable to answer calls from people in danger. When fire victims did get through, dispatchers didn’t know what to tell them about the safest way to flee the flames.

California has one of the most well-funded and advanced emergency response systems in the nation.

But some of the problems we uncovered – the potential for electrical fires, the shortcomings of alerts – were well known before the fires began, and changes already were underway or being considered at the state and federal level to fix them. Authorities certainly knew that conditions were perfect for fire and that these ferocious blazes are the new normal in California: About half of the state’s worst recorded wildfires occurred in just the past decade.

Even so, many officials defend the decisions made that first night, including Mark Ghilarducci, who directs the governor’s Office of Emergency Services.

“The events as (they) unfolded on that evening presented extreme challenges,” he said in a recent interview. “I wouldn’t call it failures – I would call it, you know, cascading challenges that occur.”

Yet he acknowledged that state and local officials are working to make changes.

Residents who lost family members, pets, homes – or who remain traumatized from fleeing the fires – aren’t interested in excuses.

Jason Meek and his elderly parents got no warning to evacuate – from neighbors or authorities. Their home in the hills above Santa Rosa is gone, and they almost died trying to drive out of flames that were at their front door by the time they woke up a little before 2 a.m., nearly four hours after Biermann heard the fire was heading toward Santa Rosa.

Meek finds it remarkable that no one bothered to warn his family about this fire.

“Like, we get all these text messages from CNN and Washington Post, or, you know, all the media that’s telling us what’s going on, on a minute-by-minute basis, in the world. But here – my world was burning, and I heard nothing,” he said. “We deserved to know that there was a fire.”

Delays in reverse 911 calls Sonoma County officials sent more than 20,000 reverse 911 calls on the first night of the fires to warn residents to evacuate. But an analysis of thousands of 911 calls and radio traffic between dispatchers and first responders shows that evacuations were requested long before the SoCo Alerts were actually sent. The map does not include opt-in text and email alerts sent by Sonoma County and Napa County officials.

Electrical problems exacerbated fires

CAL FIRE still is investigating the official cause of the wildfires that sparked that night. But in a series of lawsuits, thousands of fire survivors, along with the counties of Napa, Mendocino and Sonoma, already are blaming PG&E, California’s largest utility, for causing the fires.

Even if CAL FIRE finds that PG&E equipment did not cause the biggest fires, KQED’s review shows the utility’s equipment played a big role in slowing fire response.

KQED’s review of dispatch tape and 911 calls found that people started reporting electrical problems by 4 p.m. Callers reported high winds knocking down power lines, sparking fires. In other instances, they reported explosions.

Between 7 and 10 p.m., dispatchers in Napa and Sonoma counties discussed electrical fires, transformers blowing and power lines arcing more than 40 times. Sonoma County dispatchers also received dozens of calls about electrical incidents.

These calls drained fire resources: CAL FIRE Unit Chief Anale Burlew said officials were so busy taking calls and responding to dozens of fires –many of them electrical – that it slowed their ability to ask for desperately needed resources from neighboring counties.

Burlew said that every time an electrical incident is reported, it is rated top priority because it’s such a threat to the lives of first responders and the public.

The profusion of early fires also overwhelmed dispatch centers, not only preventing the public from reaching 911, but also hurting authorities’ ability to talk to each other.

By 10 p.m., a dispatcher in Napa County trying to connect to CAL FIRE reported getting a busy signal. At the same time, a dispatcher in Sonoma County trying to connect to Napa County also got a busy signal.

“We’re totally inundated,” a Sonoma County fire employee said to a Sonoma County dispatcher over the phone. “I can’t even count. I want to say there’s, like, 30 calls pending right now.”

Aaron Abbott, executive director of Redcom, the fire and medical dispatch center for Sonoma County, said his crews were working as hard as they could. But, he said, “everybody in the entire region was absolutely overwhelmed.”

Things got worse before they got better: The Redcom dispatch center, on the northern side of Santa Rosa, lost power as the wildfires chewed through the electrical grid. Redcom transitioned to a backup generator but lost its air-conditioning system. The room filled with hot smoke, making it difficult for dispatchers to work. And as the fire marched down the hills toward Santa Rosa, Abbott had to weigh more than once whether he needed to evacuate the 911 call center.

“It was very difficult on the dispatchers because they were not only handling a high call-volume emergency, but they were also having to endure some not-so-good conditions inside the dispatch center,” Abbott said.

Downed power lines stall rescuers

Out where the fires were burning, electrical problems also were hampering first responders’ ability to keep people safe.

At 10:30 p.m., firefighters responded to reports of an explosion and power lines down across Highway 101 in Windsor, 9 miles north of Santa Rosa, and fire on both sides.

“We’re going to fight the one on the southbound side because there’s no power lines,” the firefighter said on the phone. “The northbound one’s going to burn a while till PG&E gets out there.”

Yet many of these challenges likely could have been avoided by doing something that’s common practice in many other parts of the U.S. and even other regions of California: shutting off the power during a natural disaster.

It’s normal procedure in Southern and Eastern states where hurricanes occur. And CAL FIRE asked one Southern California utility – San Diego Gas & Electric – to shut off power more than a dozen times in 2017 to prevent fires from starting during windy conditions.

But officials in Northern California said they did not consider asking PG&E to shut down power before or during these fires, even as reports of electrical problems continued to flood in.

“That is not something that we have historically done,” Burlew said.

In the wake of these deadly wildfires, that procedure may change.

Ghilarducci, the state’s Office of Emergency Services director, said his office is working with all the state’s utilities to mitigate fire risk. And as PG&E faces the prospect of losing billions of dollars to lawsuits, the utility appears to be on board.

“Given the changing conditions related to climate change and the new normal we are all witnessing,” said PG&E spokeswoman Erin Garvey, “we have reached a determination as a company that there may be times in the future when we will need to consider proactive de-energization of certain electric lines in advance of weather events.”

Garvey added that the utility historically has relied on CAL FIRE asking it to shut down lines. But she said PG&E is in the process of talking to state regulators and elected officials about how to deal with the issue moving forward.

However, Garvey said de-energizing lines is not a panacea, and there are risks to shutting down power. For example, she noted that a shutdown could affect the ability of first responders to communicate, disrupt operations of critical facilities such as hospitals, hinder efforts to convey evacuation orders and cut power to people using medical life support equipment.

Communication failures among authorities

But electrical problems weren’t the only avoidable challenges first responders faced: KQED discovered numerous communication problems between public officials that night.

At 10:30 p.m., as the Tubbs Fire was beginning to explode, a CAL FIRE employee called a Napa County operator.

“I need you guys to send out a reverse 911 so we can tell (residents in the area) to evacuate,” the employee told the operator.

“OK, I’m just not – I’m sorry, I’m not familiar with what a reverse 911 is,” the operator responded. “I’m sorry.”

The Napa County operator didn’t know what CAL FIRE was talking about because each of California’s 58 counties uses different technologies to alert people. Some call landlines in small designated areas that emergency officials want to target for evacuations; others send text and email messages to anyone who signed up ahead of time. The text and email alerts also can go out to targeted areas, such as ZIP codes.

Even though the reverse 911 request came in from CAL FIRE at 10:30 p.m, Napa County didn’t send its first alert to residents until more than an hour later, through an opt-in system that sends texts and emails. It didn’t call home phones about evacuations until 1:38 p.m. the following day.

Ghilarducci, the state’s Office of Emergency Services director, said this patchwork of technologies is a problem.

“That’s why the WEA, the Wireless Emergency Aert system, was put in place,” he said.

The Wireless Emergency Alert system takes over your cellphone with a loud, shrill noise – like an Amber Alert. But Napa County didn’t even have access to the technology; it is still waiting for approval from the federal government. And Sonoma County officials opted not to use it.

In an interview with KQED, Chris Helgren, the former emergency manager for Sonoma County Fire and Emergency Services, said the county avoided the alert system because officials worried too many people would evacuate, clogging roads and leaving people stranded in traffic as the fire approached.

Helgren also said the system doesn’t allow officials to target a small enough geographic area and limits messages to 90 characters, and there’s no way for the county to know who received them. Federal officials are working to change some of those shortcomings.

Helgren was reassigned in February after a report by Ghilarducci’s agency found significant problems with Sonoma County’s response to the blazes, echoing many of the issues identified by KQED.

In general, Ghilarducci said, local officials tend to be overly cautious about warning people.

“There’s always obstacles that they throw out in front of them,” he said. “ ‘Oh, it’s going to cause panic. Oh, it’s going to be traffic. Oh, it may not get to the exact streets we’re talking about. It may actually be broader than we want to do.’ I think that, you know, you can’t let perfect get in the way of good enough.”

This is a lesson already being put into practice. When wildfires struck Southern California in December, Ghilarducci’s agency decided to notify residents using the WEA system. No residents died in that fire.

Officials repeatedly alerted the public too late

For many survivors, the most glaring problem that night was the lack of communication about when to evacuate and where to go.

While many officials defended their decisions, saying the fires were moving too fast to get everyone out of harm’s way, KQED found significant delays between the time that first responders recognized the need to warn residents and when officials actually sent out those alerts.

In addition to the Napa County delays, there were large gaps between when firefighters asked Sonoma County to start evacuating people and when those calls went out.

It took an hour for Sonoma County to send alerts to about 2,000 residents on their home phones. Thirty minutes earlier, Sonoma County officials did send out wireless text and email alerts to any county residents who previously had opted in to that system – but those can be more broadly targeted, so they may not have reached the right people. County officials don’t actually know how many people in the paths of the fires received those alerts.

And by that time, many people’s cellphones weren’t working anyway because so many cell towers had been taken down by the fires.

Some of these delays appear to be connected to California’s procedure for ordering evacuations: Firefighters can’t tell people to leave their homes; they can only recommend that law enforcement order an evacuation.

So that night, when firefighters on the ground saw a fire barreling toward homes, they had to call the CAL FIRE command center. Someone there then called a county dispatcher, who let the sheriff’s office know. Finally, the sheriff would decide whether to evacuate.

Sheriff’s deputies were out going door to door, but they would not make it to every house. And in Sonoma County, the Emergency Operations Center, which also can send alerts, wasn’t set up until hours after the blazes broke out.

The Sonoma County sheriff declined to be interviewed by KQED.

That meant people such as Jason Meek and his parents never got a warning – even though first responders knew for hours that the fire was headed toward his neighborhood and others nearby.

In other cases, authorities seemed to be so focused on urban fires that they failed to recognize or communicate that rural areas also needed evacuation orders.

At midnight, a Redcom dispatcher asked CAL FIRE whether the Kenwood area of Sonoma County needed to be evacuated.

“We didn’t get any reports for evacuations there,” said CAL FIRE Capt. Jeff Hoag.

“ ‘Cause I have two people, I have two people stuck on Chateau St. Jean’s (winery in Kenwood),” the dispatcher replied.

Redcom already had received about 50 calls about fires in Kenwood. But evacuation alerts to Kenwood residents didn’t go out until 3:18 a.m.

Another pattern emerged in our review of 911 calls: 911 operators couldn’t give people clear directions on which way to flee. Adrian Diaz lives in Redwood Valley, a Mendocino County town about 70 miles north of Santa Rosa. Nine people died and 546 buildings were destroyed in Redwood Valley — including Diaz’s home.

He was awakened around 1 a.m. by a neighbor as a huge, fast-moving fire rushed toward his home. While his wife piled their three boys into a car, he called 911 from their home phone. He got disconnected, so he called back from his cellphone to ask which way to evacuate.

“They didn’t tell me it was an evacuation,” he said. “They just said exit whichever way you feel is the safest. And I was like, ‘OK, well, I don’t know,’ because I didn’t know if it was worse north or worse south.”

Two hours later, someone else in Redwood Valley called 911 and asked the operator where to evacuate. The operator said she didn’t know.

“You would have to look at where the fire is and not go that way. I can’t really direct you,” she said. “I can’t picture where you are. You’re going to have to use your common sense.”

Changes are coming

These cracks in California’s emergency response system raise broader questions about how prepared any of us are for a disaster.

In 2017, natural disasters cost the United States more than $300 billion, according to the National Centers for Environmental Information, shattering the record set in 2005 by nearly $100 billion.

As the climate changes and more severe weather patterns become the new normal in California and across the country, lessons from this fire can be applied to emergency response systems in hurricane-prone areas, tornado country and flood plains.

And while state and local officials still are investigating both the causes of and responses to the October fire siege, some changes already are being made.

Ghilarducci’s office recently came out with an initial review of Sonoma County’s response that confirms many of KQED’s findings: Communication systems broke down and emergency responders weren’t properly trained.

The review also found that the county’s processes for issuing alerts and warnings were “uncoordinated, and included gaps, overlaps and redundancies.” And it concluded that Sonoma County officials should have used the Wireless Emergency Alert system – those Amber-type alerts that take over your cellphone.

The Office of Emergency Services still is conducting a wider review of the response that night, and CAL FIRE continues to investigate the causes of the fires.

But not everyone is waiting for those reviews to start making changes. A slew of state legislation has been introduced to fix some of the problems the North Bay fires revealed, including a bill to create one standard for sending evacuation alerts across all 58 California counties.

In Washington, D.C., the Federal Communications Commission is working on improving that WEA technology. Statewide, utilities and state officials are working on policies so the power grid can be shut down more quickly next time.

And in Sonoma County, local dispatchers already are being trained in what to tell people trapped by wildfires.

Ghilarducci argued that in addition to government improving its procedures, individuals across the United States also need to understand the risks of where they live and be prepared to take care of their families when a disaster hits.

“If you live in a disaster-prone state like California … you may be in earthquake country or you may be in fire country. You may be in a flood area,” he said. “You need to have a plan.”

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