The report, by the state Industrial Commission, is a blunt repudiation of the state Forestry Division's review in September, which assigned no blame but said the firefighters and their supervisor failed to "communicate effectively" as they were battling the catastrophic Yarnell Hill fire south of Prescott.
The commission voted unanimously to penalize the Forestry Division to the tune of $559,000, almost all of which would go directly to the families of the fallen firefighters.
Even though forestry commanders knew the crew's efforts were ineffective, the firefighters "were not promptly removed from exposure to smoke inhalation, burns, and death," it said.
The Industrial Commission said communications problems did play a role, but it said those problems arose because key staff members failed to show up for a morning planning meeting and because the Hotshot crew wasn't provided with adequate maps or a second escape route.
"There are lessons that can be learned from this horrible tragedy and we owe it to the firefighters who died, and to those that risked their lives fighting the Yarnell Hill Fire, to do so," Bill Warren, director of the Arizona Division of Occupational Safety and Health, said in a written statement.
Nineteen firefighters - all members of an elite response team - were killed battling a fast-moving wildfire in Arizona, marking the deadliest single incident for firefighters since the Sept. 11, 2001 attacks.
The result was critical confusion as commanders and support staff struggled to figure out where the firefighters were and how bad their situation was, the report said.
In fact, the Industrial Commission charged, the Forestry Division was squarely to blame, saying it "unnecessarily and unreasonably" put the Granite Mountain Interagency Hotshot Crew members in a pointlessly hazardous situation because it "prioritized protection of non-defensible structures and pastureland over firefighter safety."
"The Industrial Commission said that was a willful workplace safety violation by the Forestry Division in its capacity as the firefighters' employer. "