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Cramer Fire
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Accident Investigation Factual ReportCramer Fire Fatalities
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Ranger District | FMO | AFMO | Helicopter crew Type III helicopter |
Engine crew Type VI engine |
Hand crew (five person) |
Lookouts |
Salmon-Cobalt | ● |
● |
● |
|||
Leadore | 1* |
● |
||||
Challis | ● |
● |
● |
● |
1 |
|
Yankee Fork | 2* |
● |
● |
|||
Lost River | ● |
● |
● |
|||
Middle Fork | ● |
● |
● |
1 |
||
North Fork | ● |
● |
2 |
|||
TOTALS | 4 |
3 |
3 |
4 |
4 |
4 |
Fact 27: The flow of information and fire management coordination changed with the expanded fire organization, reducing the amount and type of information shared with the SO fire staff as well as their participation in critical fire management decisions. The North Fork and the Middle Fork RDs are managed by one district ranger and have the largest fire programs on the forest. The districts combined have 85 percent of the fire activity on the forest and 95 percent of the forest's roadless areas. The North Fork and Middle Fork RDs assumed greater autonomy under the new organization and coordinated less with the SO, causing friction in the new organization, confusion below the operations staff officer as to SO staff roles and responsibilities, and possibly reduced organizational effectiveness. The deputy FMO noted, for example, that the SO fire staff had been less involved in day-to-day fire management and that he was marginalized in the expanded organization. Although the forest supervisor was aware of some organizational tensions and problems, he did not feel they hampered fire safety. He stated that he "took some of the sting out of the district running everything" by incorporating checks and balances in the fire management decisionmaking process. The regional director of aviation and fire management (A&FM) stated that upcoming reviews of the forest's fire organization might surface and address the issues and concerns about fire management on the forest (statements: 9, 12, 21, 24, 27, and 28).
Fact 28: The forest supervisor, the regional director of A&FM, and a deputy regional forester thought the SCNF fire organization worked well. From a communication standpoint, the regional fire staff has a conference call every Monday with forest FMOs in R-4 to discuss current issues, safety messages, and other fire business. The operations staff officer on the SCNF and the forest FMO also have a formal conference call every Monday with the district rangers to share fire management information. Every Tuesday, the district FMOs and the forest FMO have a conference call to discuss fire danger, general fire management strategies, and specific fire strategies and tactics (statements: 1, 9, 15, 24, and 27).
Fact 29: Fire funding decreased after 2001. The forest had an expanded organization, insufficient funds to fill numerous vacant positions, and conflicting strategies for managing fire vacancies. The forest FMO and his staff supported reducing overhead at the forest and district levels in order to fill initial attack positions. The district rangers and the operations staff officer generally felt that overhead was more critical because of the hard decisions that needed to be made during project fires. Although the forest's 2003 initial budget allocation was 51 percent of MEL (most efficient level), the final allocation was 95 percent of MEL during the third quarter of the fiscal year. The forest postponed strategic organizational decisions because of delayed budget allocations, and later decided to fill key overhead/supervisory fire positions to provide leadership needed on fires. In the interim, existing forest fire personnel typically performed their own duties as well as the duties of the vacant fire positions. Broader organizational staffing issues, however, remain unresolved (statements: 9, 15,21,27, and 28; record: 1).
Fact 30: The Cramer Fire was on the North Fork RD. The FMO position on the North Fork RD remained vacant 1 to 1½ years prior to and during the Cramer Fire, although a new hire for the position arrived shortly afterward. The delay in filling the district FMO position was partly because of concerns by the forest FMO that the district did not have adequate, long-term funding. The AFMO on the North Fork RD is Alan Hackett,who had been on the district since May 2001. He was detailed to the FMO position for a 120-day acting assignment. For interim periods, when others were not detailed to the position, Hackett was assigned the duties of the district FMO (statements: 1, 14, 15, 21, 25, 27, and 28).
Fact 31: Red-card certification on the forest is very tightly managed and monitored, ensuring accurate and up-to-date qualifications of fire personnel. The forest established a red-card committee which reviews the qualifications of fire personnel on the forest. It also has an incident commander (IC) committee that reviews IC qualifications, performance weaknesses, and needed training or experience. To monitor performance, the forest requires evaluations of fire personnel before returning from a fire assignment. Even with this level of oversight, some personnel were concerned that the addition of new or inexperienced people may impact safety and situational awareness on fires. The forest supervisor and North Fork/Middle Fork district ranger considered Alan Hackett, the Cramer Fire IC Type III on July 21 and 22, to be one of the safest Type III ICs on the forest. Hackett is trained and qualified as a Type III IC. Other personnel on the fire also met agency qualifications (statements: 1, 12, 15, 26, 27, and 32).
Fact 32: The forest was able to accomplish all of its preseason fire training, which included training for returning firefighters and fire shelter training. Each line officer conducted an "expectations briefing" for ICs, helicopter foremen, and other supervisors. If fire personnel missed the briefing, the forest supervisor and the operations staff officer briefed them later to ensure that all fire personnel were fully informed (statement: 15).
Fact 33: The forest's safety record has been above average in R-4. The forest supervisor consistently emphasized firefighter and public safety as his highest priority and cautioned against taking risks that jeopardized human life (statements: 12, 21, and 27).
Fact 34: During fire season each year, the forest supervisor received daily fire briefings from his staff, visited with personnel on fires to stay informed, met with the crews, participated in district orientations, and emphasized his safety message at several different locations. In June of 2002 and 2003, the forest supervisor met with his Type III, IV, and V ICs to discuss expected weather conditions, implications for the fire season, and public and employee safety (statement: 27).
Fact 35: The regional office (RO) monitors compliance of the Thirtymile Action and Prevention Plan, communicates the importance of fire training, funds training activities, and stresses the need to use the Great Basin Incident Organizer on wildland fires staffed by forest employees. Each year, the district rangers and FMOs on the SCNF jointly conduct after-action reviews to improve fire management on the forest. District FMOs monitor fire operations for safety and compliance with work/rest guidelines (statements: 9, 16, 24, and 27).
Fact 36: The forest supervisor, the North Fork/Middle Fork district ranger, and the operations staff officer indicated that past and current fire experience, training, safety messages, job hazard analyses, and/or red-card qualifications constitute effective risk management on the forest (statements: 1, 15, and 27).
Fact 37: Even though the fire season started slowly because of average winter snowpack and precipitation, June turned hot and dry. A burst of late spring moisture resulted in pine fuel growth and good grass cover through all elevations. Up until June 10 or 11, the forest had approximately 20 fires (statements: 15 and 27).
Fact 38: On July 12, between 1400 and 1500, the Tobias Fire on the Leadore RD began growing rapidly, expanding from 400 acres to 13,000 acres in 6 hours. By the following weekend, fires increased because of lightning activity (statement: 15).
Fact 39: Facing heightened fire danger, the forest requested $9,000 for preventing human-caused fires associated with an air show on the southern end of the forest (statement: 28).
Fact 40: On Saturday, July 19, the recently ignited Blackwall and Tobias Fires required Type II incident management teams. [————] operations staff officer, provided support to the team on the Blackwall Fire while [————], the forest FMO, supported the team on the Tobias Fire. The deputy FMO left for a house-hunting trip in central Oregon (statements: 12 and 28).
Fact 41: On Sunday, July 20, additional lightning starts were reported, including the Crystal Fire, Dutch Lakes Fire, and the Cramer Fire. The Dutch Lakes Fire was given highest priority. If it reached stands of bug-killed trees, it had the potential to burn into the town of Stanley, ID. At 400 acres, the Crystal Fire was second priority, and the Cramer Fire, at 20 acres, was third priority. [————] the district ranger for the North Fork and Middle Fork RDs, was working as a supervisory dispatcher in the SO. She had the Blackwall and Crystal Fires burning on her districts. [————] informed her that she had a new fire, the Cramer Fire, on her district and indicated what resources were being dispatched. She was shown maps that indicated where the Cramer Fire was located (statements: 1, 5, 12, 15, and 28).
Fact 42: On Monday, July 21, [————] and [————] were preparing to in a regional fire preparedness review, which had been canceled the previous year. The regional office was aware of the fire situation on the forest, but chose to hold the review as scheduled. [————] was involved in a transition from a Type II to a Type III team on the Tobias Fire and a consultation with the RO about initial attack issues. Later in the day, he was also preparing an inbriefing for the Crystal Fire Type II team. [————] was at the North Fork RD. She informed Alan Hackett, her AFMO, of the Cramer Fire. She briefed him on the fire location, identified [————] [————], the district FMO on the Salmon-Cobalt RD, as the IC, and told Hackett to contact [————]. Hackett was unable to contact [————] and subsequently talked with [————] around 0830. Shortly after a call between [————] and Hackett, [————] approved Hackett as the Cramer Fire IC. [————] worked the rest of the morning on North Fork RD business, and at midday ordered a Type II team for the Crystal Fire. She traveled to Salmon, ID, for a Fish and Game meeting and remained in Salmon for most of the day. In the late afternoon, she heard Hackett over the radio express concern about the Cramer Fire burning down to the Salmon River road. She ordered a patrol for the road through dispatch. She traveled to the Blackwall Fire to serve as the agency administrator's representative and returned home at 1930 (statements: 1, 9, 15, and 28).
Fact 43: In response to extreme burning conditions and the large fires on the forest, central Idaho dispatch was aggressive about sending resources to new fire starts, including the Cramer Fire (statements: 8 and 36).
Fact 44: By Tuesday, July 22, the forest was focusing on the Tobias, Crystal, and Blackwall Fires, while ensuring that the Dutch Lakes Fire was contained. In the meantime, the forest had two new fire starts. The RO fire preparedness review began that morning, involving [————] and [————]. At 1300 or 1400 a new large fire, the Frog Pond Fire, started near Lost Trail Pass, and [————], who was participating in the RO review, decided to take members of the review team to the fire to witness it first hand. Radio and phone communications were limited. His attention was focused on the Frog Pond Fire and the Blackwall Fire, which had the potential of burning together. [————] was at the Middle Fork RD early Tuesday morning, working on a wildland fire situation analysis (WFSA) and delegation of authority for the Crystal Fire. She briefed the Type II team at 1000 and spent the morning and early afternoon with them. During the afternoon, she spent time managing issues related to the Frog Pond and Blackwall Fires. She had no contact with the North Fork RD until she called the RD at 1700 (statements: 1, 15, 27, and 28).
Fact 45: According to the SCNF operations staff officer, an IC typically would talk to the district ranger, district FMO, forest FMO, forest duty officer, or zone duty officer to discuss strategy and tactics on a fire (statements: 1 and 15).
Fact 46: In the absence of a district FMO or AFMO, the zone duty officer can provide guidance to an IC on initial attack (statements: 1 and 15).
Fact 47: When discussing strategy and tactics with the district, the forest FMO is the principal contact with the district FMO. The operations staff officer communicates with the district rangers about fires on their districts, although the forest FMO may also, depending on the circumstances (statement: 15).
Fact 48: The operations staff officer generally does not get involved with the strategy and tactics on Type III incidents such as the Cramer Fire (statement: 15).
Fact 49: In a discussion with the North Fork/Middle Fork district ranger on Sunday night, July 20, [————] informed [————] that the strategy for the Cramer Fire was to use a helicopter for bucket work and a hand crew to control the fire at the smallest acreage. She heard this again in a secondhand conversation between Hackett and [————] on Monday morning, July 21. From that point on, her information about the strategy and tactics on the Cramer Fire came from the radio on Monday afternoon and from radio logs after the accident on July 22 (statement: 1).
Fact 50: The zone duty officer or district FMO and the IC typically use the Incident Response Pocket Guide extended attack transition analyses to make decisions about incident complexity (statement: 15).
Fact 51: After consulting with the IC, the zone duty officer or district FMO informs the SO fire staff when a fire is exceeding a district's capabilities (statement: 15).
Fact 52: The forest uses four guidelines to analyze the complexity level of a fire (statement: 15; records: 11, 12, 13, and 27).
Fact 53: Based on discussions with the SO fire staff, preparing wildland fire situation analyses (WFSAs) on all but Type I fires was the responsibility of the ranger district. In the case of the North Fork RD, the AFMO would prepare a WFSA with the North Fork/Middle Fork district ranger, who would approve the WFSA (statements: 1, 14, and 15).
Fact 54: The SCNF fire management plan identifies two trigger points that define when a fire transitions from initial attack to extended attack (appendix e):
1—Suppression efforts have not succeeded or are not expected to reach containment within 24 hours.
2—The initial attack incident commander (IC Type IV or IC Type V) 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. The Cramer Fire became an extended attack fire when [————], the IC Type IV, requested an IC Type III at approximately 1938 on Sunday, July 20 (statement: 20; record: 15). This transition request should have triggered the need for a complexity analysis and WFSA. No complexity analysis or WFSA was prepared on July 20, 21, or 22.
Fact 55: The North Fork/Middle Fork district ranger did not know if a complexity analysis had been done for the Cramer Fire (statement: 1 ).
Fact 56: According to the district ranger, no WFSA was prepared, because she had not been advised that the fire had escaped and that a WFSA was required. Normally, she would receive that information by radio or cell phone, and the zone duty officer or district FMO would have kept her informed. She did know, however, that an IC Type III had been ordered on July 20, and she approved her North Fork AFMO as the IC Type III early in the morning on July 21. The forest FMO, zone duty officer, and CID also knew that an IC Type III had been ordered on July 20 (statement: 1).
Fact 57: The operations staff officer recognized that the Cramer Fire was an extended attack fire with an IC Type III, but larger fires on the forest received higher priority. The North Fork/Middle Fork district ranger, the forest FMO, CID, the zone duty officer, and the operations staff officer should have known, based on the FMP and the transition to an IC Type III, that a complexity analysis and WFSA were required (statements: 1, 14, 15, 20, and 36).
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