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Cramer Fire

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


Factual Report

Executive Summary

   (facts 1 - 57)
   (facts 58 - 201)
   (fact 202)
   (facts 203 - 237)


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

Gallery of Cramer Fire Report Images

Accident Prevention Plan

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


HFACS—"Swiss cheese" model of Accident Causation

Adobe PDF and Microsoft Word versions of documents related to the Cramer Fire can be downloaded from the U.S. Forest Service website.


Management Evaluation Report

Cramer Fire Fatalities
North Fork Ranger District
Salmon-Challis National Forest
Region 4
Salmon, Idaho - July 22, 2003


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.

  1. 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.

  2. 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.

  3. 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.

  4. The SCNF needs to maintain and calibrate its RAWS prior to each fire season to ensure accurate and reliable weather information.

  5. 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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