Finding 1. The Salmon-Challis National Forest (SCNF) fire management plan (FMP) provided adequate direction for management of fires (findings: 1a and 1b).

The FMP has two different trigger points that define when a fire transitions from initial attack to extended attack. It clearly defines the followup requirements, such as a complexity analysis and a wildland fire situation analysis (WFSA), once a fire reaches extended attack status (appendix e).
The FMP addresses the hazards of fire suppression in the Salmon River Breaks. It recognizes the effects that steep slopes have on fire behavior, rapid uphill fire growth, and rolling firebrands. The FMP also cautions that fire line construction at midslope is dangerous and that underslung fire lines are hard to secure and hold. The FMP states that the Salmon River Canyon experiences up slope winds that are pronounced during the summer, often resulting in winds far different from those predicted in general area fire weather forecasts. Midslope fire suppression tactics were used on the Cramer Fire on July 21 and 22 during extreme burning conditions (facts: 107, 154, 166, and 193; appendix e).

Fire Management Organization

Finding 2. Responsibility for managing Type II through Type V fires was assigned to the district rangers (DRs) on the SCNF, which placed a considerable fire management workload on the DR of the North Fork and Middle Fork ranger districts (RDs). There was a critical fire management vacancy on the North Fork RD. There were no initial attack resources from the North Fork RD on duty or available on July 20 (findings: 2a-2d).

SCNF district rangers have made, for some time, fire management decisions on Type III, IV, and V fires. Beginning in 2001, authority for fire management decisions on Type II fires transferred from the supervisor's office to the district rangers, increasing their authority, responsibility, and fire management workload, particularly on the North Fork and Middle Fork RDs (facts: 23, 26, and 27).
The SCNF was having a difficult time staffing and aligning its fire organization and setting priorities in response to reduced, fluctuating, and/or delayed funding. This resulted in a critical vacancy on the North Fork RD--the district fire management officer (FMO)--and inconsistent long-term management and leadership (facts: 29 and 30).
The FMP requires that incident commanders (ICs) Type III be full time, dedicated ICs with no collateral duties. When the assistant fire management officer (AFMO) became the IC on the Cramer Fire, he was not to perform his duties as AFMO on the North Fork RD. During the Cramer Fire, no personnel were assigned to the FMO or AFMO positions on the North Fork RD (facts: 30, 90, 147, 197, and 207; appendix e).
When the Cramer Fire was reported on July 20, the North Fork RD had no FMO and the AFMO had just returned from three days off. The district helitack crew was off-forest, lengthening the response time to the Cramer Fire. It took 15½ hours from the time the IC Type IV ordered an IC Type III for the IC Type III to arrive on the Cramer Fire and assume command (facts: 30, 63, 69, 75, 90, 99, and 107).

Finding 3. The SCNF increased the number of positions in its fire organization when it received National Fire Plan funding in 2001 (fact: 23).

Finding 4. There were different perceptions on the SCNF of how well the fire organization functioned. The performance of the fire organization was becoming a source of increasing concern among some of the forest-level fire staff and at the regional office. Limited action had been taken to address the state of the fire organization (facts: 27 and 28).

Finding 5. Fire management information was routinely conveyed through the region, forest, and district (fact: 28).

Finding 6. The forest requested one-time, limited severity assistance while it was experiencing dangerous conditions (facts: 19 and 39).

Finding 7. Personnel assigned to the Cramer Fire were qualified for their positions (findings: 7a-7b)

The SCNF has a rigorous system of training and qualifications for its fire management personnel (facts: 31 and 32).
Line officers considered the AFMO on the North Fork RD a safe IC Type III. The IC Type III qualifications of the AFMO meet the requirements of agency policy. Other personnel assigned to the fire met the qualifications in Forest Service Manual (FSM) 5109.17 (fact: 31).

Transition from Initial Attack to Extended Attack

Finding 8. According to the FMP, a fire transitions from initial attack to extended attack when an IC Type IV or V requests additional resources (increasing incident complexity to the next level), suppression efforts have failed, or suppression efforts may not contain the fire within 24 hours (appendix e).

Finding 9. When the Cramer Fire went into extended attack status, the change from initial attack to extended attack was not acknowledged, recognized, or reported by the IC, the North Fork/ Middle Fork district ranger, the forest FMO, central Idaho dispatch, or the Salmon-Cobalt FMO/zone duty officer. As a consequence, no complexity analysis or WFSA, required by the FMP, were conducted and there was no communication regarding the change in fire status (facts: 50-57, 69, 74, 75, 90, and 99).

Finding 10. In the morning on July 21, the IC assessed fire conditions and potential in order to provide information for the incoming IC Type III. The IC gave the incoming IC Type III his incident organizer and passed on information about suppression resources and weather (facts: 84, 85, 86, 88, and 99).

Fire Suppression Strategy and Tactics

Finding 11. The strategy for July 20 was to secure the west side of the fire, because the east flank was burning actively and there were insufficient personnel on the fire. The entire plan was abandoned late that evening due to dangerous conditions (facts: 71, 72, 73, and 77).

Finding 12. Between July 20 and July 22, there was minimal discussion of Cramer Fire suppression strategy and tactics among the forest fire staff, the North Fork/Middle Fork district ranger, the zone duty officer, and the IC (facts: 42, 45, 46, 47, 49, 90, and 123).

Finding 13. On July 21 and July 22, fire suppression strategy and tactics on the Cramer Fire did not provide for safe and effective suppression operations. The IC Type III failed to continually reevaluate the situation and modify his plan when fire conditions changed and when requested resources were not available (findings: 13a-13k).

From the time the fire was reported until midday on July 21, there was no suppression action taken on the fire other than two retardant drops (facts: 62, 66, 73, 76, 77, 89, 94, 101, and 102).
Between July 20 and July 22, both ICs on the Cramer Fire had a containment strategy and tactics for controlling the fire, which they communicated to assigned incident personnel. Suppression objectives for the fire were not clearly articulated by the forest FMO, North Fork/ Middle Fork district ranger, zone duty officer, or the IC Type III (facts: 42, 69, 72, 90, 99, 123, 133-137, 142-145, and 167; appendix e).
The hand crew was unable to hold the fire line on the afternoon of July 21 because of increased fire activity and pulled back to protect H-1. The IC decided to abandon suppression action on the fire, while a helicopter continued bucket work (facts: 107, 113, and 115).
The IC Type III's strategy for July 21 was to hold the fire in place using aerial resources and a hand crew. In the afternoon, helicopters used buckets to support the hand crew, which was hot spotting, cold trailing, and building line up the east flank of the fire (facts: 99, 107, 108, and 115).
The IC's strategy on July 22 was to contain the fire at its current size. The planned tactics were to anchor the fire, construct hand line to the east and west from the anchor, and cold trail and build line down the west flank from the ridge above, after a helispot had been cleared and a hand crew flown in. Bucket and retardant drops would be used in conjunction with ground forces (facts: 133, 136, 141, and 143).
The strike team leader and the lead plane pilot felt that the strategy for July 22 was overly optimistic (facts: 153 and 164).
On July 22, the IC, two crew bosses, and air attack felt that H-2 was a safe location based on early morning conditions. The lead plane pilot felt that H-2 was a safe location based on light fuels and rocky areas in the Cache Bar drainage (facts: 136, 137, 152, and 187).
Although the IC Type III did not receive the resources and support he requested on July 21, he remained confident that he could contain the fire on July 22 and did not change his suppression strategy (facts: 99, 107, 123, 125, 137, and 143).
By midafternoon on July 22, the suppression plan was partially executed. An anchor was not established on the fire and the plan to place a hand crew on H- 2 was abandoned but not communicated to the rappellers (facts: 143, 154, 167, 171, 172, 181, and 184).
On July 22 as on July 21, the suppression strategy failed. Hand crews were pulled off the fire line in the afternoon of both days to ensure their safety (facts: 174, 179, 181, and 193).
From late morning until midafternoon on July 22, Cove Creek helibase contacted the rappellers three times and the IC one time for updates on their progress. The IC and two crew bosses, as well as the H-2 rappellers, underestimated the amount of work and time required to clear H-2, delaying timely retrieval from H-2 (facts: 136, 157, 163, 167, 183, 189, and 220).

Finding 14. On the morning of July 22, the IC and two other overhead personnel discussed strategy, tactics, lookouts, escape routes, and safety zones (facts: 133, 134, 135, 136, and 137).

Finding 15. During his morning briefing on July 22, the IC covered the range of topics found in the Incident Response Pocket Guide briefing checklist (facts: 143, 144, and 145).

Finding 16. There was good attention to safety at the forest level and in the early stages of the Cramer Fire. However, there were significant safety lapses on the Cramer Fire prior to the fatalities (findings: 16a-16i).

Line officers on the SCNF complied with agency safety policy by communicating the importance of firefighter and public safety as the highest priority in fire suppression activities (facts: 33 and 34; appendix e).
The region, forest, and districts emphasized and monitored safety using - multiple venues (facts: 33, 34, 35, and 36).
On July 20, the IC recognized, assessed, and monitored the hazards on the fire and took safe actions to mitigate them (facts: 71, 73, 77, and 78).
Based on a review of timesheets, each individual on the Cramer Fire was within their work-rest and length of assignment guidelines, including the AFMO on the North Fork RD who became the IC Type III on July 21 after three days off (facts: 75, 90, and 99).
On July 21, after assessing changing conditions on the fire and monitoring crew demeanor, the IC took measures to assure crew safety in the afternoon (facts: 111 and 115).
The FMP requires a safety officer on Type III incidents. A safety officer was not requested or assigned to the Cramer Fire (fact: 123; record: 24; appendix e).
Briefings on July 21 and July 22 did not emphasize the Ten Standard Firefighting Orders, the 18 Watch Out Situations, or ongoing risk assessments required by agency policy nor did they acknowledge extreme fire behavior potential in the Cramer Fire area (facts: 105, 143, 144, 145, and 154; appendix e).
On July 22, the IC placed an employee at risk east of the fire while fire activity was increasing (facts: 171 and 173).
On July 22, firefighters continued to be dropped off at H-1 even though the helispot was being threatened by fire (facts: 168, 171, 174, and 178).

Finding 17. Visibility of the slopes below H-2 was limited by topography and vegetation, obscuring the rappellers' view of fire below them (facts: 3 and 151).

Fire Management Resources

Finding 18. There were inadequate resources and a logistical inability to fully utilize available resources to implement the ICs' strategies. On July 22, there was confusion about the availability and positioning of some resources, and helicopters were not available to retrieve the rappellers at a critical moment of need (findings: 18a-18j).

On July 20, jumpers from the McCall, ID, base were unable to staff either the Crystal or the Cramer Fires due to high winds (facts: 61 and 62).
On July 20, approximately 40 minutes after arriving on the Cramer Fire, the IC Type IV requested an IC Type III for the fire (facts: 67, 68, and 69).
One jumpship, one air attack aircraft, one airtanker, two engine crews, one hand crew (which got lost enroute to the fire), and one helitack crew were dispatched to the Cramer Fire on July 20. The only suppression action on July 20 was two retardant drops (facts: 61-67).
On July 20, personnel on the fire consisted of an IC Type IV, an IC Type IV trainee, and five engine crew members (facts: 67 and 72).
Because dispatch instructed the IC to keep his five firefighters ready for initial attack on July 21, he could not use them for suppression action on the Cramer Fire on July 20 (facts: 78, 94, and 102)
The IC Type IV kept a helicopter on the ground when it could have been used on the morning of July 21 to assist with fire containment and control while the fire was relatively inactive (facts: 89, 98, 99, 103, and 121).
Type I crews were available through the National Interagency Coordination Center but were not requested by central Idaho dispatch. In addition, the IC did not request Type I crews or sufficient management personnel (fact 123; record 25).
Because the crew shuttles took more than 3 ½ hours on July 22, most of the ground forces did not reach the fire line until the middle of the afternoon (facts: 153 and 178).
On July 22, lead plane 41 was confused as to the number and location of resources and assumed that the personnel at H-2 had been transported to H-1 (facts: 164 and 187).
Helicopters were unavailable for immediate dispatch when the rappellers called for pickup, delaying the launch to retrieve them (facts: 188, 189, 190, 194, and 195).

Finding 19. Suppression in the afternoon on July.21 consisted of one retardant drop, bucket drops, and hand line construction that began midafternoon (facts: 107, 108, and 115).

Finding 20. During the morning of July 22, one helicopter was doing bucket drops on the fire. In the afternoon, two helicopters were doing bucket work, multiple loads of retardant were dropped on the ridge above Cramer Creek, and three hand crews were building fire line (facts: 141, 153, 158, 161, 165, 168, and 171).

Weather Information

Finding 21. Weather information was not aggressively sought. Weather information that was obtained did not represent the Cramer Fire site (findings: 21a-21f).

Due to lack of station maintenance, weather observations from remote automated weather stations were of questionable accuracy and provided potentially erroneous National Fire Danger Rating System indices (fact: 13).
Winds were much stronger than predicted in the spot and zone forecasts on July 21 (facts: 88, 99, 112, and 113).
Because a spot weather forecast was not requested for the July 22, updated information from the National Weather Service, indicating stronger winds than specified in the zone forecast, was not relayed to personnel on the fire (fact: 145).
Because spot weather forecasts were viewed as inaccurate and unreliable, fire personnel on July 22 tended to rely on the general fire weather forecast and the previous day's weather and fire behavior for their information (facts: 14, 88, 131, and 145).
There was substantial reliance on Long Tom Lookout for weather observations on the fire. Weather observations aired from Long Tom Lookout were invalid for much of the fire area due to substantial differences in elevation and site characteristics (facts: 15, 170, and 176.
Weather observations taken on July 22 were significantly different from those communicated by Long Tom Lookout (facts: 170 and 176).

Finding 22. Fire activity on the SCNF increased in July due to hot, dry weather and multiple lightning starts, indicating the potential for new starts to grow rapidly (facts: 38, 40, and 41).

Finding 23. Thermal belts are common at midslope locations in the Salmon River Breaks and promoted active burning on the Cramer Fire well into the late night and early morning on July 21 (facts: 11, 79, 81, and 126).

Finding 24. The National Weather Service's Pocatello Office issued a spot weather forecast in a timely manner on July 21 (facts: 85 and 88).

Finding 25. Crews were informed during the July 22 morning briefing that conditions had been getting progressively warmer and drier the previous two days (facts: 130, 131, and 145).

Fuels and Terrain

Finding 26. Fuel and terrain conditions on the Cramer Fire lent themselves to extreme fire behavior and difficult fire suppression (findings: 26a-26d).

Steep slopes predisposed areas to rapid, uphill, fire growth and problems with firebrands rolling downhill (fact: 4; appendix e).
Live fuel moisture was at a critically low level, and the Burning Indices (Bls) and Energy Release Components (ERCs) indicated dangerous conditions (facts: 10 and 19).
Fire exclusion in the north part of the SCNF resulted in a shift from a high frequency, low intensity fire regime to one of lower frequency, higher intensity (fact: 20).
Shiny-leaf ceanothus is capable of burning intensely with rapid rates of spread, yet this information was not included in the FMP (fact: 9, 187, 196, and 201).

Fire Behavior, General

Finding 27. Fire behavior was consistent each day--calm in the morning and severe in the afternoon (findings: 27a-27g).

The fire became active in the early evening on July 20, growing from 3 to 25 acres in 2 ½ hours in light fuels on steep slopes (facts: 62 and 68).
From late night until very early morning on July 21, conditions remained warm and dry, allowing continued fire growth and spread and precipitating the call for additional resources. At approximately 0230 on July 21, fire activity was minimal and remained that way until approximately 1130 (facts: 79, 81, 82, 96, 98, and 103).
Fire activity began to increase by late morning and early afternoon on July 21 and built through the late afternoon with increasing, gusty winds (facts: 103, 110, 112, 113, and 115).
In the evening on July 21, the fire remained active with isolated torching and grew an additional 140 acres in 2 ½ hours (facts: 114, 115, and 117).
On July 22, fire activity in the morning was low, backing and creeping through grass with scattered smokes in open timber (facts: 138, 150, and 152).
Fire activity increased late morning on July 22 near H-1. By early afternoon, the fire had become active to the east and northeast but was backing downhill at low intensity (facts: 156, 166, 168, and 173).
By midafternoon on July 22, strong, gusty winds increased fire activity around H-1 and made a run to the east in the Cramer Creek drainage (facts: 174, 179, and 185).

Finding 28. Even though the Salmon River Breaks are known for their potential for extreme fire behavior and some crew members were aware that seasonal conditions were extreme, other personnel on the Cramer Fire did not expect fire behavior in the afternoon of July 22 (facts: 19, 131, 143, 167, and 187).

Lookouts

Finding 29. There were no effective lookouts for the rappellers at H-2 (Findings: 29a-29c).

The 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 (facts: 135, 143, 148, 155 and 167; record 8).
The strike team leader running ground operations on July 22 was watching out for the safety of his three crews. He was not in a location to see the H-2 operation and was not responsible for the rappellers (facts: 143, 144, 153, 154, 181, 184, and 193).
On July 22, during the time of critical fire behavior transition: Lead plane 41 assumed dual responsibilities as lead plane and air attack, affecting his situational awareness; H-166 and H-193 were busy with crew shuttles, refueling, and maintenance; and 133-KA was refueling (facts: 161, 164, 165, 185, 188, and 198).

Escape Routes and Safety Zones

Finding 30. 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. Near H-1 , the black was a safety zone, but the unburned sagebrush field was a survival zone. There were no effective safety zones for the rappellers at H-2. Near H-2, the black on the east side of the ridge during the uphill fire run may have been a survival zone, but the old burn/ceanothus brush field was neither a safety zone nor a survival zone (facts: 134, 137, 196, and 201 ).

Finding 31. Between 1505 and 1524 prior to being overrun by fire, the rappellers communicated with the helibase five times in quick succession. During those calls, they repeatedly requested a pickup and reported during the third call fire and smoke below them (facts: 189, 190, 194, 199, and 201 ).

Finding 32. The rappellers were asked at approximately 1510 if they needed to go to a safety zone and they replied no. Helicopter retrieval became the primary escape route to safety for the rappellers (facts: 189, 190, 191, 194, 199, and 201).

Finding 33. The rappellers were found outside a previously identified safety zone with their flight helmets. Their rappel equipment and chain saws were prepared for transport at H-2, indicating that they were awaiting pick up at H-2 (facts: 219, 222, and 223).

Finding 34. When the rappellers left H-2, they carried their line gear with them, but did not deploy their shelters (facts: 200, 202, and 223).

Fire Behavior, Cache Bar Drainage

Finding 35. The seriousness of the fire in the Cache Bar drainage was underestimated (findings: 35a-35f).

On July 22, the rappellers were notified of low intensity ground fire below the West Ridge of the Cache Bar drainage as soon as they were dropped off. Subsequent sightings of ground fire in this area from midmorning to early afternoon were not acted on (facts: 150, 153, 164, and 167).
After 1400 on July 22, fire activity increased dramatically on the fire. Fire that had been smoldering in the Cache Bar drainage became an active flaming front (facts: 174, 179, and 180).
Development of an active fire front in the Cache Bar drainage on July 22 was observed from the air by lead plane 41 and Cramer air attack-- as much as 50 minutes before the fire reached H-2, but this information was not conveyed to H-2 (facts: 180, 185, and 187).
Beginning at 1500, the fire, driven by strong westerly winds, made rapid, intense, updrainage runs simultaneously in the Cramer Creek and Cache Bar drainages (facts: 186, 187, and 196).
When the fire front reached H-2, the intensity and rate of spread were much greater than had been anticipated (facts: 187 and 201 ).
Conditions were not survivable with or without a fire shelter at the fatality site because of hot gases and extreme temperatures from an intense fire front (facts: 201 and 202).

Post Accident Response

Finding 36. Because of extremely smoky conditions, multiple attempts were made to contact and locate the rappellers after the fire overran H-2 (facts: 205, 208, 211, 212, and 213).

Finding 37. During the first half hour after loosing contact with the rappellers, the IC checked on the safety of personnel in the vicinity of H-1 and was dispatching Cramer Fire resources to the Stoddard Fire. More than 30 minutes after losing contact with the rappellers at H-2, the IC became engaged in the search-and-rescue operation (facts: 204, 206, 207, 208, 211, and 212).

Leadership on the Cramer Fire

Finding 38. Leadership on the Cramer Fire was inadequate to provide for safe and effective suppression operations (findings: 38a-38e).

The IC Type III did not request a safety officer on July 21 or 22 (fact 123; record 24).
On July 21, the IC Type III's confidence in his ability to contain the fire was based on his expectation of receiving the requested resources the following day. On July 22, he remained confident he could contain the fire with the same strategy even though he did not receive the requested resources (facts: 114, 123, 137, and 143).
On July 22, the IC's view of the fire came from two reconnaissance flights. The rest of the day he was at the Cove Creek helibase, 13 miles from the Cramer Fire, managing logistics and operations (facts: 133, 147, and 166).
On July 22, when the IC made his decision to retrieve the rappellers from H-2, ½ hour elapsed before a helicopter was launched to get them, and that launch was requested by the rappellers. When the IC made his decision, a helicopter had just left the helibase to pick up a helitack crewmember near the fire and could have retrieved the rappellers at the same time (facts: 178, 184, 189, and 195).
During the critical period prior to and after contact was lost with the rappellers on July 22, the IC was also functioning as the district FMO/AFMO, performing multiple collateral duties on the radio (facts: 197, 198, and 207).

Finding 39. On July 20 and 21, there were different perceptions by the North Fork/Middle Fork district ranger, the zone duty officer, and the forest FMO of who was and would be the IC Type III and duty officer for the day (facts: 74, 75, and 90).

Finding 40. The IC Type III sized up the fire on July 21, briefed his crew, and was onsite for the entire afternoon, running operations (facts: 98, 99, 105, 107, 110, 113, 114, and 115).

Finding 41. On July 22, Cramer Fire personnel identified the strike team leader as the IC, operations section chief, and/or division group supervisor (facts: 123, 144, and 164).

Finding 42. The Indianola helitack assistant foreman was the rappel spotter for the H-2 rappellers and, after the rappel operation, became the Cove Creek helibase manager responsible for helicopter operations. He directed helibase communications to check periodically on the rappellers' progress (facts: 150, 157, 163, 183, and 191).

Finding 43. After seeing increasing fire activity around H-1 and in the Cramer Creek drainage during the afternoon recon on July 22, the IC requested assistance from the forest FMO in reviewing his strategy (facts: 175 and 179).

Management Oversight

Finding 44. The SCNF assigned responsibility for the Cramer Fire to the IC Type III but did not provide oversight. Those who should have provided oversight focused attention on other priorities. When concerns about management of the fire were surfaced, followup on these concerns was inadequate (findings: 44a- 44f).

The operations staff officer, who conveys fire information to the district rangers, was occupied with Type II fires on the forest as well as a regional preparedness review from July 20-22 (facts: 40, 42, 44, and 47).
The North Fork/Middle Fork district ranger was occupied as a supervisory dispatcher for the central Idaho dispatch center, with Type II fires on her districts, and with non-fire business from July 20- 22. Her involvement with the Cramer Fire was limited (facts: 41, 42, 44, 49, 90, and 129).
The forest FMO, who is the liaison between the zone duty officer/district FMOs and the operations staff officer, was occupied with multiple fires on the SCNF, a regional preparedness review, briefings, and related fire business from July 20-22. His involvement with the Cramer Fire was limited until the afternoon of July 22 (facts: 40, 41, 42, 44, 47, 51, 90, 123, 179, 192, and 207).
The forest deputy FMO was off the forest during the Cramer Fire, and no one was assigned his duties in his absence (fact: 40).
After his initial, limited involvement on the Cramer Fire on July 20, the zone duty officer, who was the point of contact for the Cramer Fire IC, shifted his attention to other fire business until he became the Cramer Fire IC in the early evening of July 22 (facts: 45, 46, 74, 75, 90, 91, and 217).
When the forest aviation officer (FAO) surfaced concerns to the forest fire staff about resource use, crew disorganization, and/or IC competency on the Cramer Fire, the forest operations staff officer discussed those concerns with the FAO and reported them to the North Fork/Middle Fork district ranger. The district ranger did not follow up after talking with the FAO (facts: 121, 122, and 129).

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Cramer Fire Dedication

Lessons Learned

Management Evaluation Report

Factual Report

Gallery of Cramer Fire Report Images

Accident Prevention Plan

OIG Investigation

OSHA Investigation

HFACS—"Swiss cheese" model of Accident Causation

Accident Investigation Factual Report

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

Findings

Fire Management Plan Direction