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An internal probe of the Maui Police Department’s response to the Aug. 8 wildfires highlighted the many challenges officers faced to save lives while revealing an understaffed force that dealt with communication, equipment and other problems.

Six months after multiple fires ravaged Maui and led to the deaths of at least 100 people in Lahaina, the department released a 98-page preliminary after-action report that provided a detailed account of its response and 32 ways to improve for future emergencies.

“We have an obligation to the community we serve, we have an obligation to the policing profession, and we have an obligation to those we lost to document what went right, what were the challenges, and how can we get better and move forward,” Maui Police Chief John Pelletier said Monday during a news conference.

“We want to make sure that we learn the lessons that were there,” he said.

For the first time, the location of where the victims were found was made public.

Most were discovered mauka of Honoapiilani Highway, and only four of the dead were found on Front Street. One of those was in a structure, two were found over a seawall and one person died near a car that was not theirs.

“You heard all the reports of cars stuck on Front Street,” Pelletier said. “Not one person died in a car on Front Street.”

A video from the investigation showed that cars being evacuated going north along Front Street were moving well until a utility pole fell, blocking the northbound section of Honoapillani Highway. The southbound section was full of vehicles being turned around and away from the fire.

Overall, approximately 42 bodies were recovered from inside structures, 39 from outdoor locations, 15 from inside vehicles, and one in the water. An additional three deaths were later reported to have occurred in a hospital on Oahu due to fire-related injuries, the report said.

In the days after the fire, there was some criticism of the police’s actions to evacuate people to safety, with some people claiming they were being sent toward the fire.

The investigation detailed officers navigating a chaotic situation in which visibility was difficult from the smoke from the fast-moving fire. High winds of 60 to 80 mph made it hard to hear and move, and chaotic information and misinformation was coming fast and furious from officers on the scene, thousands of 911 and other emergency calls and social media.

Downed trees and utility poles at key intersections and stretches of road blocked critical evacuation routes for the seaside town, including at one point the Lahaina Bypass when the fire was jumping the road.

Some areas were simply too engulfed with flames for officers to enter. In one case, an officer’s car caught on fire, the report said.

While cellphone and internet service was out in Lahaina during the main fire of Aug. 8, the police department’s radio communication, using the countywide Public Safety Radio System, was “fully functional throughout,” it said.

But the investigation found there were “periodic miscommunications,” primarily due to the high winds that made it difficult to hear what was being said, as well as confusion with call signs due to the large number of officers who self-deployed. At the peak of the incident, 49 officers were staffing the Lahaina District.

“These officers were experiencing critical events in front of them at the same time in multiple different locations, leading to a lot of information being aired over the radio. At most times, the radio traffic was being monitored by and responded to by a single dispatcher,” the report said.

The simple recommendations to these issues: have optional radio earpieces issued to all officers and create a procedure for call signs for officer who self-deploy. Both are in progress of being done, the report said.

With blocked roads, the report says MPD officers created escape routes.

“One officer utilized his own straps to tie to a fence and his police vehicle to pull a fence down. Congested traffic used this newly created escape route,” the report says.

A recommendation was to equip every supervisory police vehicle with a breaching kit for removing debris such as a downed tree from roadways.

Pelletier said at different parts of the day of the fires, he was at the police headquarters in Wailuku and later that night set up the Maui Police Department Operations Center.

With a red flag warning in place for Maui, the first fire started at approximately 12:22 a.m. in Olinda in Upcountry Maui.

At 4:45 a.m., the assistant police chief was assigned to Maui County’s Emergency Operation Center, which was partially activated at that time. It would not be fully activated until 5:50 p.m., when the second Lahaina fire had already destroyed much of the town.

“At the EOC, this was the appropriate rank,” Pelletier said. “The president of the United States does not go into a tank. You have to make sure that you allow your people to do what they need to do.”

The first Lahaina fire began at approximately 6:35 a.m. on Aug. 8 near the Lahaina Intermediate School, prompting evacuations of multiple neighborhoods, with officers blaring on their loudspeakers to get out.

That fire also prompted the county’s required Situational Report notification, which was emailed at about 8:18 a.m. to the county’s executive staff advising them about the Lahaina fire in the area of Lahainaluna Road and Kuialua Street. That was one minute before the fire was 90% contained, according to the timeline in the report.

“For various reasons, there were no other situational reports or notifications emailed. Reasons included the volume of calls for service, the start of and the rapid growth of the afternoon Lahaina fire, the lack of power and internet service and other exigent circumstances,” the report said.

Notifications were being relayed by phone, and later when cellular communication went down, by police radio, the report said. It added that “Lahaina command maintained communication with executive staff members throughout the incident, to maintain the flow of information from the field to the EOC and DOC.”

But important information did not reach Mayor Richard Bissen, who during a live broadcast with KITV4 at 6 p.m. on Aug. 8 did not appear to understand the gravity of what was happening in Lahaina.

The report’s timeline shows a series of evacuations over the course of the day as fires spread in Lahaina, Olinda, Kula and Kihei.

“Some of these actions would include driving into and through the areas of the fire,” said Sgt. Chase Bell, the lead investigator of the preliminary report who interviewed every officer involved in the response. “There were areas that our officers were not able to get to despite their best efforts.”

With fires raging in different parts of the island, resources were stretched thin. The Lahaina district had to initially use the 16 officers available. While that number is up from the five patrol officers who normally man the district at one time, police said they could have used more help.

“Although we feared that there were fatalities, none were nor could be confirmed until August 9th at 8 a.m.,” the report said.

Authorities recovered 40 remains the first day after the fires. Another 50 remains were found during search and rescue efforts the next two days, the report said.

After the fires, Pelletier created the Morgue Identification and Notification Task Force that operated out of a central location at the Wailuku Forensic Facility. It included the efforts of more than 150 federal law enforcement officers to narrow a list of more than 3,000 missing persons to the current three people.

The landowner next to the facility lent the property for storage of refrigerated and other containers. Teams of anthropologists and experts in bone examination worked in the field and the morgue.

“An anthropologist would work oftentimes on their hands and knees in a very detailed effort to recover everything that was recoverable,” said Dr. Jerry Stuelpnagel, the coroner’s physician, who was on the task force. “Anthropologists, once they would find remains, would process the site all the way down to the naked concrete, recovering everything. Sometimes the fragments were as small as a quarter or smaller. … Many of the remains were extensively fragmented and separated, amplifying our initial death toll estimates.”

But through fingerprints, DNA, dental records and medical device registrations, all victims were able to be identified. One of the most difficult was a person who had no living biological relatives. But investigators learned the person traveled annually to the mainland to see a family friend, and they obtained a brush the person had left behind.

“After the hair follicles from the hairbrush were analyzed, we were able to obtain a positive identification,” said MPD officer Brad Taylor, a task force member. “This presents one of the many unique challenges we faced throughout this process.”

The preliminary report makes up about 90% of the final after-action report, which will be completed in six to 12 months, Pelletier said.

The preliminary report has been shared with the Police Executive Research Forum, which will distribute it to the entire law enforcement profession for feedback to account for the other 10% of the final report.

“We want to get feedback from the law enforcement profession so that we can make sure that there was nothing we missed,” Pelletier said.

Civil Beat’s coverage of Maui County is supported in part by a grant from the Nuestro Futuro Foundation.