Lessons Learned
“Safety
Zone” newsletter, July, 2004
Lessons Learned —
author, date unknown
One-Year Anniversary Letter
by Kelly Close, FBAN
Declaration on Cramer
Redactions, by James Furnish, April, 2005
FSEEE v. USFS, FOIA
Civil Lawsuit Order,
December, 2005
FOIA
Request to USFS, December, 2005
FOIA Appeal to USFS,
February, 2006
Management Evaluation Report
Investigation Team Information
Synopsis of the
Cramer Fire Accident Investigation
Causal Factors
Contributing Factors
Addendum
Factual Report
Executive Summary
Narrative
Background
(facts 1 - 57)
Preaccident
(facts 58 - 201)
Accident
(fact 202)
Postaccident
(facts 203 - 237)
Findings
Appendix A
Resources on the Fire
Appendix B
Cramer Fire Timeline
Appendix C
Fire Behavior and Weather
Prior Conditions
Initial Phase
Transition
Phase
Acceleration
Phase
Entrapment
Phase
Appendix D
Equipment Found at H-2 and the Fatalities Site
Appendix E
Fire Policy, Directives, and Guides
OIG Investigation
OIG FOIA Response,
February, 2005
2nd FOIA Request to OIG,
April, 2006
2nd OIG FOIA Response,
August, 2006, (1.4 mb, Adobe .pdf file)
OSHA Investigation
OSHA Cramer Fire Briefing Paper
• Summary and ToC
• Sections I-IV
• Sections V-VII
• Section VIII
• Acronyms/Glossary
OSHA South Canyon Fire
Briefing Paper
Letter to District
Ranger, June 19, 2003
OSHA Investigation Guidelines
OSHA News Release
• OSHA Citation 1
• OSHA Citation
2
• OSHA
Citation 3
USFS Response
OSHA FOIA Letter
Adobe PDF and Microsoft Word versions of documents related to
the Cramer Fire can be downloaded from the U.S.
Forest Service website.
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Management
Evaluation Report
Cramer Fire Fatalities
North Fork Ranger District
Salmon-Challis National Forest
Region 4
Salmon, Idaho - July 22, 2003
Addendum
Issues surfaced during the course of the investigation that are not directly
related to the cause of the accident but may require attention to improve
fire management and firefighter safety on the SCNF.
-
Given the potential rate of spread in ceanothus as its growing season
progresses from late June to early September, the SCNF should include
predominant brush species on the forest in routine live fuel moisture
samplings and communicate fuel moisture conditions and ramifications
to forest and district fire management staffs.
-
Because fire personnel on the forest believe that spot weather forecasts
from the National Weather Service Pocatello Off ice are inaccurate
and unreliable, they tend to rely on the general fire weather forecast
and the previous days' weather and fire behavior for their information
on the fire line. The SCNF fire staff should periodically evaluate
the level and quality of service they receive from the Pocatello office
and work more closely with that office to ensure that the annual,
fire-weather operating plan is complete, current, and adequate for
the forest's needs.
-
Fire line supervisors need to reinforce the importance of taking
frequent fire weather observations on the line, determine if other
fire weather sources such as Long Tom Lookout are appropriate, accurate,
and needed, and interpret and use the information to make real-time
fire operations decisions.
-
The SCNF needs to maintain and calibrate its RAWS prior to each fire
season to ensure accurate and reliable weather information.
-
The IC Type III and strike team leader raised concerns about the
performance of the Ferguson Type II crews (18A and 18B) on the Cramer
Fire. On July 20, 18B got lost enroute to the fire and had difficulty
communicating on the radio. As a result, the crew did not arrive in
time to initial attack the Cramer Fire. On July 21, 18B and, on July
22, 18A and 18B were pulled off the line due, in part, to poor line
production, supervision problems, and/or disorganization. The Ferguson
crews are Type II, IA certified. IA certification requires that each
crew have three ICs Type V and that 60 percent of the crew members
have 1 or more years of firefighting experience. A review of the Ferguson
crews' training records and qualifications showed that their ICs Type
V were qualified on large fire assignments and that their task books
were signed by the company president. The Forest Service contracting
officer at NIFC with responsibility for Type II crew contracts should
verify the certification process and sign off procedures for contract
crew qualifications.
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