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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.


Accident Investigation Factual Report

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

Appendix E—Fire Policy, Directives, and Guides

FSM 5100—Fire Management
FSH-6709.11—Health and Safety Code Handbook
Interagency Standards for Fire and Fire Aviation Operations 2003
Incident Response Pocket Guide
Thirtymile Hazard Abatement Monitoring Plan
Salmon-Challis National Forest Fire Management Plan
Ten Standard Firefighting Orders
18 Watch Out Situations

FSM 5100—Fire Management

5130—Wildland Fire Suppression
A Wildland Fire Situation Analysis (WFSA) shall be used to document suppression strategy decisions for an incident that is expected to exceed, or has exceeded, the action planned for in the fire management plan (FSM 5131.1)…Consider fire behavior, the availability of suppression resources, the values of natural resources and property at risk, direction in the Forest land and resource management plan, and the potential cost of suppression.

5131—Suppression of Wildfires
Request the appropriate level of Incident Management Team based upon the complexity findings of the WFSA (FSM 5131.1).The responsible line officer shall ensure that the designated Incident Commander is briefed regarding wildfire suppression objectives, considerations, and constraints.

5131.11—Preparation Requirements
A WFSA must be completed when:
1. Wildfire escapes initial action or is expected to exceed initial action.

5133—Organization and Management of Wildfire Suppression Operations
  5133.1—Wildland Fire Management Organization

Assign the appropriate level of incident management team based on a complexity analysis done within the WFSA.

5135—Fire Suppression Safety
All activities shall reflect a commitment to firefighter and public safety as the first priority.

5135.4—Safety Guidance
The Fire Orders, Lookouts/Communications/Escape Routes and Safety Zones (LCES), and Watch Out Situations contain important basic guidance for safe fire management activities.The FSH 5109.32a, Fireline Handbook, and FSH 6709.11, Health and Safety Code Handbook, list the Fire Orders and Watch Out Situations. During fire assignments, all employees shall be alert continuously for Watch Out Situations. Wildfire suppression actions must comply with the Fire Orders and incorporate appropriate mitigation measures based on the Watch Out Situations and LCES.

FSH-6709.11—Health and Safety Code Handbook

25—Protection and Development
  25.13—Wildland Firefighting
    25.13a—Safety Practices

Conduct risk assessments on an ongoing basis and take measures to mitigate risks to prevent accidents. Basic safety and health practices for wildland firefighting are:

1. The 10 Standard Fire Orders.

2. The Watch Out Situations.

7. Fire Situation Assessment.
    a. Conduct continual situation assessment and followup, which is essential.
    c. Ensure that firefighter safety is not compromised. Do not deviate from established safety practices.
    d. Post qualified lookouts with adequate communication for crews and in position to see danger points.

Interagency Standards for Fire and Fire Aviation Operations 2003

Chapter 10—Incident Management
Introduction—The Incident Complexity Analysis and the WFSA assist the manager in determining the appropriate management structure to provide for safe and efficient fire suppression operations.

Incident Response Pocket Guide

There are eighteen decision points on the Extended Attack Transition Analysis dealing with fuels, weather, communications and resources. If you check yes on three or more items out of the 18 to consider ordering an incident management team. A quick run through of the analysis, brings up four yes answers.

Thirtymile Hazard Abatement Monitoring Plan

Implementation action—Prepare a complexity analysis on every plan at time of initial attack as part of the size up. Documentation Required.

Responsibility—Line officers, fire management officers, incident commanders.

Implementation action—Monitor the effectiveness of the planned strategy and tactics and to:

  1. Immediately delay, modify, or abandon firefighting action on any part of a wildland fire where strategies and tactics cannot be safely implemented.
  2. Execute suppression actions when and where they are safe and effective.
  3. Ensure that all firefighting actions are in full compliance with the Ten Standard Fire Orders and that the mitigation of the applicable Watch Out Situations has been accomplished.
  4. Maintain command and control of all fireline resources.

Responsibility—Incident commander.

Salmon-Challis National Forest Fire Management Plan

Section II—Relationship to Land Management Planning and Fire Policy

B. Management Policies Concerning Fire.

  1. Firefighter and public safety is the first priority in every fire management activity.
  2. Sound risk management is a foundation for all fire risk management activities.

The Salmon-Challis National Forest is well versed in the many policies following the Thirtymile Fire. These policies, aimed at improving firefighter safety and directing the implementation of actions in the Thirtymile Accident Prevention Plan of December 14, 2001 and the Thirtymile Hazard Abatement Plan of March 26, 2002, have been incorporated into the development of this Fire Management Plan.These plans and the recent Interim Directives (5100-2003-1, 5120-2003-2, and 5130-2003-3) for 2003 have been included in appendix p. Also included in the same appendix are the Monitoring Plan and Incident Checklist for use in implementing the abatement actions of the Thirtymile Hazard Abatement Plan. These documents have been distributed to the districts for use in safety sessions, and to develop procedure for incident management.

Section III—Wildland Fire Management Strategies

B. Wildland Fire Management Goals.
Achieve a program where firefighter and public safety is the highest priority in every fire management activity.

C. Wildland Fire Management Options.

    1. Wildland Fire Suppression

All wildfire starts are sized up to determine fire cause, potential for spread and potential to cross jurisdictional boundaries.

An appropriate management response is implemented on all fires unless the fire is determined to be a wildland fire use incident.

All wildfires that escape initial attack will have a Wildland Fire Situation Analysis (WFSA) completed in a timely manner.The WFSA will serve as the decision record for the selection of the appropriate management response.

D. Description of Wildland Fire Management Strategies by Fire Management Unit

Control problems and dominant topographic features

Suppression Non-WUI FMU

The topography in steep areas has a significant effect on fire behavior, fuels and weather. Steep slopes predispose areas to rapid uphill fire growth as well as contribute to a major problem with rolling firebrands. Fire line construction at midslope is very dangerous and on these slopes underslung fire lines are hard to secure and even more difficult to hold.Topography across the area has a very mark effect on fuels because of the differences in moisture and surface heating across the landscape; fuel type varies as a result of the differences in elevation, available moisture and differences in aspect. In addition to the direct physical affects that can be seen on fuels and fire behavior, topography also influences local weather conditions, specifically winds. Differential heating across the landscape results in the development of local upslope/ upvalley breezes and these are very common often very pronounced during the summer months. Canyon topography in the area also tends to channel winds and often results in local wind conditions far different from those predicted in general area fire weather forecasts. Night time thermal zones are also common within the unit especially in deeper canyons. These thermal zones, which contribute to active fire behavior at night, are particular common on fires burning in the lower Salmon River Canyon.

Topography also has a very significant effect on spotting. Firebrands lofted from elevated positions on slopes or ridges can travel very significant distances and can contribute to long range spotting during severe weather conditions. Rolling material is also common in these steep areas and can result in significant fire growth, in holding problems and jeopardize fire fighter safety.

Firefighter safety is a significant concern in this Unit as a result of the influences topography has on the way fires burn. Managers should consider safety as it relates to this topography when sizing up fires for suppression actions. Midslope fires are of particular concern and should be carefully evaluated to assure that firefighters safety is not compromised by fire below fire suppression personnel. Caution should also be taken with down hill line construction with close attention given to the required safety measures prescribed in the downhill guides.

Values to be protected in this Fire Management Unit include structures, infrastructure, improvements, T and E species, wildlife habitat, commercial timber, range values, recreation areas, cultural resources and public safety. The objective for fire management within the Unit emphasizes suppression. Wildland fire use is not authorized and will not be used as a fire management strategy. Fires will receive aggressive initial attack, a Wildland Fire Situation Analysis (WFSA) will be prepared is initial action is unsuccessful in suppressing the fire.

Section IV:Wildland Fire Management Program Components

B. Wildland Fire Suppression
3. Initial Attack

Initial attack is an aggressive suppression action consistent with firefighter and public safety and with values to be protected. The Central Idaho Coordination Center uses WildCAD Run Cards to dispatch resources based on the current response level across the forest.
d. Response times

Responses in the Suppression non-WUI can be expected in the 20 to 45 minute range depending on the specific location of the fire. These locations are by nature more likely to be in remote locations accessible best by helicopter, or via backcountry road.

4. Extended Attack and Large Fire Suppression

A wildfire is considered to be in extended attack status when:
• Suppression efforts have not succeeded or are not expected to reach containment within 24 hours.

• The initial attack incident commander (ICT 4 or ICT5) requests additional resources that result in fire complexity attaining Type III status within or following the first 24 hours following the arrival of the first suppression resources.

b. Implementation Plan Requirements—WFSA development

Type III incident management.

A Type III incident commander (IC) will manage incidents that reach a Type III complexity level. This will be a full time dedicated IC with no collateral duties.The forest has assembled a Type III team to manage these incidents through to completion or until transition to a Type I or II incident management team.

7. Other Fire Suppression Considerations


Safety is the number-one priority for all personnel engaged in or supporting fire management activities on the forest.

Fire management work is one of the most hazardous jobs encountered by Forest Service personnel.The incident commander and all supervisors will always put the safety of his/her personnel first. There is no fire situation so serious that the life of anyone should be risked in order to get to the fire sooner, get the fire out quicker, or to keep the burned areas smaller.

All employees will abide by the Safety First policy. Each employee has a responsibility for his/her personal safety and that of fellow employees. It is also everyone’s responsibility to call attention to any unsafe practice that is observed.

1. All fire personnel will follow the Ten Standard Firefighting Orders and the 18 Watch Out Situations and shall practice the principles of Lookouts, Communications, Escape Routes, and Safety Zones (LCES). These basics of fire fighting survival will be utilized as a checklist for supervisory personnel on the fire, and as a source for other fire line personnel to pose questions to supervisory personnel whenever they have concerns about their personal safety. All firefighters will carry and utilize their Incident Response Pocket Guide.

2. All Type III and more complex incidents will be staffed with a qualified safety officer.

Ten Standard Firefighting Orders

All Ten Standard Firefighting Orders were violated or compromised.

1. Keep informed on fire weather conditions and forecasts.
Spot weather forecasts were not requested for July 22. Few weather observations were taken on the line during the entire fire. Fire personnel relied heavily on weather observations from Long Tom Lookout that did not represent the Cramer Fire site (IC Type III and Cramer Fire personnel).

2. Know what your fire is doing at all times.
Due to the steep terrain and multiple aspects, lookouts were not in vantage points to view the entire fire.The visibility at H-2 was limited due to terrain and vegetation. On July 22, the IC’s view of the fire came from two reconnaissance flights.The restof the day he was at the Cove Creek helibase, 13 miles from the Cramer Fire (IC Type III and Cramer Fire personnel).

3. Base all actions on current and expected behavior of the fire.
Actions were based more on the observed fire behavior in the morning than what was predicted to occur based on the seasonal severity, weather forecast, and previous days’ fire behavior (IC Type III and Cramer Fire personnel).

4. Identify escape routes/safety zones and make them known.
Three of the four safety zones identified by the IC and two crew bosses were not safety zones on the afternoon of July 22, during conditions of extreme fire behavior. Hear H-1, the black was a safety zone, but the unburned sagebrush field was a survival zone. Near H-2, the black on the east side of the ridge during the uphill fire run was a survival zone, but the old burn/ ceanothus brush field was neither a safety zone nor a survival zone (IC Type III, Central Oregon Regulars crew boss, Indianola assistant helitack foreman).

5. Post lookouts when there is possible danger.
The IC’s plan for placement of lookouts was not clearly communicated to personnel assigned to the fire. No lookout with a view of H-2 or the Cache Bar drainage was posted on July 22 to monitor fire in the Cache Bar drainage and to communicate critical weather and fire behavior information to the rappellers. Aviation resources over the fire could not function full time as lookouts for ground crews given their other duties and responsibilities (IC Type III).

6. Be alert. Keep calm. Think clearly. Act decisively.
On July 22, when the IC made his decision to retrieve the rappellers from H-2, he did not act decisively by immediately removing the rappellers from H-2. During the critical period prior to, and after contact was lost with the rappellers, the IC was functioning as the district FMO/ AFMO, performing multiple collateral duties on the radio (IC Type III).

7. Maintain prompt communications with your forces, your supervisor, and adjoining forces.
On July 22, critical observations of fire activity in the Cache Bar drainage were not communicated to the IC and the rappellers at H-2. The IC did not update the rappellers on H-2 about revised strategy and tactics. More than 30 minutes elapsed after loosing contact with the rappellers at H-2 before the IC became engaged in the search and rescue operation (IC Type III, air attack, lead plane 41).

8. Give clear instructions and ensure they are understood.
On July 22, the IC’s instructions regarding the locations of lookouts were not well understood.The IC dropped off a helicopter crew person east of H-1 without a plan, a briefing, or a designated safety zone (IC Type III).

9. Maintain control of your forces at all times.
On July 22, the IC was not in control of his forces on the fireline, deferring operations to his strike team leader. He did not supervise and adequately contact, monitor, or coordinate with the H-2 operation (IC Type III).

10. Fight fire aggressively, having provided for safety first.
Initial attack suppression efforts on the Cramer Fire were inadequate on July 20 and 21, causing the fire to grow in size and complexity under extreme burning conditions. Midslope suppression tactics were used on July 21 and 22 during extreme burning conditions.There were significant safety lapses prior to the fatalities. The safety of the rappellers was compromised by focus on fire activity in the Cramer Creek drainage and the eventual burnover of H-1 (North Fork/Middle Fork district ranger, forest FMO, zone duty officer, IC Type III).

18 Watch Out Situations

Nine of the 18 Watch Out Situations were present and not mitigated.

1. Fire not scouted and sized up (NA).

2. In country not seen in daylight (NA).

3. Safety zones and escape routes not identified (NA).

4. Unfamiliar with weather and local factors influencing fire behavior (NA).

5. Uninformed on strategy, tactics, and hazards (NA).

6. Instructions and assignments not clear.
On July 22, the IC’s instructions regarding the locations of lookouts were not well understood.The IC dropped off a helicopter crew person east of H-1 without a plan, a briefing, or a designated safety zone (IC Type III).

7. No communication link with crew members/supervisor.
The IC did not supervise and adequately contact, monitor, or coordinate with the H-2 operation (IC Type III).

8. Constructing fireline without safe anchor point.
Anchor points were not established (IC Type III, strike team leader).

9. Building fireline downhill with fire below.
The tactics for the west side of the fire were for a crew to build downhill fireline from H-2 (IC Type III).

10. Attempting frontal assault on fire (NA).

11. Unburned fuel between you and the fire.
The rappellers at H-2 had two drainages of unburned fuel (Cramer Creek and Cache Bar) below them (IC Type III).

12. Cannot see main fire, not in contact with anyone who can.
The visibility at H-2 was limited due to terrain and vegetation. No lookout with a view of H-2 or the Cache Bar drainage was posted on July 22 to monitor fire in the Cache Bar drainage and to communicate critical weather and fire behavior information to the rappellers (IC Type III).

13. On a hillside where rolling material can ignite fuel below.
Rollouts were a common occurrence during all phases of the Cramer Fire. A combination of backing and rolling allowed fire to establish itself in the Cache Bar and Cramer Creek drainages. (IC Type III).

14.Weather is getting hotter and drier.
Fire activity on the SCNF increased dramatically through June and into July from hot, dry weather and multiple lightning starts, indicating the potential for new starts. Conditions had been getting progressively hotter and drier during the Cramer Fire (IC Type III, Cramer Fire personnel, North Fork/Middle Fork district ranger, forest FMO).

15.Wind increases and/or changes direction.
Wind gusts on the Cramer Fire increased markedly during the afternoon of July 22 and changed direction. Personnel on the fire did not account for the predicted changes in windspeed and direction for the afternoon (IC Type III and Cramer Fire personnel).

16. Getting frequent spot fires across line (NA).

17. Terrain and fuels make escape to safety zones difficult (NA).

18. Taking a nap near fireline (NA).

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