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.
|
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
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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