“People didn’t die from the smoke. People didn’t die from the fire. People died because they didn’t know something was coming.”
-Joseph Solis, former 911 dispatcher employee and police officer in Sebastopol, CA
The California Governor’s Office of Emergency Services recently published a report from an independent assessment of Sonoma County’s disaster communication plan following the catastrophic wildfires on October 8, 2017. As these wildfires grew, an estimated 100,000 people were evacuated, more than 5,000 structures burned, and 25 lives were lost making the event the most destructive wildfire in California history.
While the state's Assessment Team determined Sonoma County had in place an established public alert and warning system with the means to alert a wide range of County residents and visitors of the impending dangers, the investigation concluded specific procedures for using those alert and warning capabilities were “uncoordinated and include gaps, overlaps, and redundancies”.
The state’s independent review found Sonoma County emergency staff failed to prepare for the wildfires and had an outdated understanding of technology, unorganized emergency alerting protocol, and undertrained staff. The report also warns that the weaknesses found in Sonoma County's disaster communication plan are not unique, and many other local agencies could experience similar destruction in the event of another natural disaster.
Below are some of the report’s key findings, including how Sonoma County emergency management failed to protect residents before the wildfires started and recommendations for improving the county's disaster communication plan before the next disaster.
(You can access the full report here.)
Report Finds Gaps in Sonoma County’s Disaster Communication Plan
The gaps found in Sonoma County's disaster communication plan point towards the same shortcoming - a lack of trust. Alert operators did not trust their ability to issue public warnings because of their lack of training with the system, incident commanders did not trust the WEA capabilities of their notification system to properly alert local residents, and emergency services leaders did not trust the emergency action plan to evacuate residents safely.
Unclear Roles and Responsibilities
The roles of the alert originator, authorized to direct the issuance of public alerts and warnings, and that of an alert operator, trained in the technical operation of the warnings tools, were often confusing. Several individuals interviewed during the investigation reported a lack of clarity with regard to the authority to make decisions and issue warnings. According to the report findings:
“Personnel inferred that those individuals who had received technical training were, at least de-facto, authorized to make alerting decisions. Under the pressure of a fast-moving and complex emergency situation, this ambiguity could lead to delays and inconsistency in alert and warning issuance.”
Lack of Social Science Training
The Assessment Team found it troubling that both decision-makers and operators of the county's notification system reported having little or no training on the ‘social science’ aspect of issuing public warnings. This includes understanding the thresholds and criteria necessary for issuing a public warning as well as how to use effective language in warning messages. These best practices also include effectively communicating pre-designated evacuation routes to local residents, preparing for traffic control, and ensuring shelter center information is readily available to those in need.
Sonoma Emergency Manager Chris Helgren, who was removed from the job days before the release of the state review, said he was afraid a mass alert would trigger mass evacuations and block the narrow roads that firefighters needed to access. Helgren’s fears, regardless of their merit, highlight the poor internal education and trust emergency management workers have of local emergency action plans.
Documentation of Procedures and Templates Were Poor
The investigation revealed that checklists or detailed procedures for deciding what warnings to issue, when, and in what form appeared to be almost entirely absent. Alert-message templates that were available were largely focused on flood emergencies or evacuation, leaving alert operators to improvise alert messaging content. This placed more pressure and confusion on alert operates who were already undertrained on the emergency alert system.
Poor Situational Awareness Impacted Alert Messaging
The Assessment Team found the technical alert and warning systems to be functioning adequately, especially considering the impact of the wildfires on the area's communication infrastructure. Unfortunately, emergency management leaders were unable to monitor the progress of firefights on the ground. Lack of knowledge regarding the movement of first responders and resources in the field severely impacted overall situational awareness. Becuase of this lack of communication, decisions were being made on which areas should receive evacuation warning messages without alert operators being fully informed on the state of the wildfires.
Recommendations for Improvement for Sonoma County's Disaster Communication Plan
Based on the assessment of Sonoma County’s alert and warning system, the California Office of Emergency Services made eleven recommendations for local officials moving forward - we highlight some of the most important recommendations below.
Improve Training for Emergency Management Workers
The report recommends that all potential public safety incident commanders be trained and authorized to order public warnings and evacuations when necessary. Training should focus on the science of effective warnings and the “when, why, and how” of alerting. This recommendation also includes alert operators and personnel at dispatch centers and emergency operation centers. These workers must know how to compose and transmit effective emergency alert messages during an emergency.
Development of Pre-Scripted Templates
Sonoma County was prepared for emergencies that evolve at a slower pace, such as storms and floods, and less so for fast-moving fires requiring urgent public warnings and rapid evacuations, according to California’s top emergency services official Mark Ghilarducci. When it came to the documentation of procedures and templates, the Assessment Team uncovered much-needed room for improvement.
The report recommends pre-scripted message templates be developed to manage short-notice evacuations, care and shelter locations, and other important information residents need during an active emergency. Recommendations also include the development of ‘fill-in-the-blank’ style templates to be used for other common protective action plans such as prepare-to-evacuate, shelter-in-place, boil-water, and more. Alert-messaging templates during the October wildfires were focused on flooding and left emergency service operates no guidance for crafting an effective alert warning message on the fly.
Establish Refresher Training and Practice Sessions
Operators should practice sending alerts over various systems periodically throughout the year to stay familiar with the process. At the same time, incident commanders and other officials authorized to order public alerts should be reviewing their responsibilities and emergency resources and stay up-to-date on best practices for warning messages.
Underutilization of your alerting system may result in catastrophic consequences for residents. Not only will this prove dangerous during an emergency event, but non-emergency drills by alert operators unfamiliar with the system can result in another false alert like we saw in Hawaii. Annual system reviews by alert operators in Sonoma County could have made them feel more comfortable sending out an alert warning despite the stress of the growing wildfires.
Specify the Use of WEA
State evaluators challenged the county emergency service division staff’s reasons against using the Wireless Emergency Alerts, commonly used for Amber Alert child abduction messages. The state review concluded Sonoma County officials decided long before the October wildfires to not trust the WEA system or the WEA integration capabilities their private vendor was charging them $14,500 to utilize. Some residents received their first WEA notifications from the county after the storm and debris flow had already hit. Sonoma County didn’t even attempt to use the emergency broadcast system that hits TVs and radios because emergency management officials were unable to trust the system's reliability.
The report suggests Sonoma County officials review the use of WEA for all critical public alert and warnings. Officials should be considerate of residents who are hearing-impaired or have access and functional needs as well as visitors and tourists, all of whom would benefit from WEA alerts.
(Is your vulnerable population's management plan as detailed as your infrastructure resiliency efforts? Here's what to consider.)
Review and Expand Planning for Rapid Evacuations
The county’s evacuation planning was based on storm situations and periodic flooding of the Russian River, threats that tend to be more gradual in onset and within a smaller geographic area than fires, the report said. The county’s alert procedures and plans “were misunderstood or not directly applicable to this fast-moving, complex fire situation,” the report said.
Sonoma Emergency Manager Chris Helgren’s fears of mass evacuation ultimately influenced his decision to not use the national Wireless Emergency Alert system, leaving many residents unaware of approaching fires. Recommendations for Sonoma County emergency services include the review and development of rapid evacuation plans for fires, chemical releases, active shooters, and other immediate hazards. This should include estimates of evacuation traffic from neighborhoods and key traffic corridors toward likely shelter locations.