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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.


David Bahr
1216 Lincoln St.
Eugene, Oregon 97401
Tel: (541) 485-2471
Fax: (541) 485-2457
bahr @

Attorney for Plaintiff





Civ No. 05-6015-HO


I, James R. Furnish, declare as follows:

1. I am the former Deputy Chief of National Forest Systems for the USDA-Forest Service. The Deputy Chief for NFS is the third-ranking official below the Chief and Associate Chief and responsible for the day-to-day administration and policy-making of the national forests. Prior to my appointment as Deputy Chief, I was the forest supervisor of the Siuslaw National Forest in Oregon.

2. I retired over three years ago from a career of 34 years with the U.S. Forest Service. I live in Rockville, Maryland, and am a consultant on forestry issues. I received a B.S. in forest management from Iowa State University in 1968. My career with the Forest Service involved progressively responsible positions in both research and administration in Maine, South Dakota, Colorado, Wyoming, Oregon, and Washington, D.C. From 1977 to 1984, I was a district ranger on the Tensleep District of the Bighorn National Forest in Wyoming. From 1984 to 1989, I was a staff officer on the San Juan National Forest in Colorado. In December 1991, I became the Deputy Forest Supervisor of the Siuslaw National Forest in Oregon. I became the Acting Forest Supervisor in October 1992, and served in that capacity until I was appointed as Forest Supervisor in April 1994. I served as Forest Supervisor until May 1999. I then became Deputy Chief of the U.S. Forest Service in Washington, D.C., where I served until October 2001. I retired from the agency in January 2002.

3. Although I began my career as a forester, my duties and experiences expanded over time to include many areas of expertise, including program areas such as fire, wildlife management, soils, hydrology, recreation, and administrative areas such as budgets. For example, I initially was trained in fire suppression as a fire fighter, and was involved in fighting fires for several years. Later in my career, I was trained and served as coordinator in both 1994 and 1996 among several agencies when fire suppression needs exceeded the capacity to respond, and it became necessary to prioritize which fires had the greatest needs.

4. During my tenure as Deputy Chief, I was the Investigation Team Leader for the Thirty-Mile Fire to discern the cause of the deaths of four Forest Service firefighters in 2001. I supervised all aspects of that investigation, including preparation of the Accident Investigation Factual Report, the counterpart to the Cramer Fire Report at issue in this case.

5. I have fully reviewed a publicly available copy of the Cramer Fire Report.

6. The Thirty-Mile Fire report identifies by name, function and/or job title all of those who participated in the events that led to that tragedy. Nothing was redacted from the publicly released version of the report. To the best of my knowledge, that was the case for all of the Forest Service's accident investigation reports, prior to the issuance of the Cramer Fire report. It is my professional opinion that there is no rational, organizational or performance-based reason to withhold from public disclosure the names, functions and/or job titles of those individuals included in the Cramer Fire Report.

7. I did receive some pressure from within the Forest Service to prevent public disclosure of the identities of those involved in the Thirty-Mile incident. However, I do not believe, nor was I was ever instructed, that identifying the names would violate the Privacy Act, the Freedom of Information Act or disclose personnel, medical, or similar information in an inappropriate manner. Rather—interpreted against the background of my 34-years of experience within the Agency and my understanding of the statutes and regulations governing accident investigations and public accountability regarding Forest Service operations—I believe that efforts to withhold disclosure of the names of individuals in such reports merely reflects a policy preference of some within the Forest Service who are concerned that such disclosure may prove embarrassing for the Agency. While I acknowledge the possibility that this policy of secrecy could conceivably be instructed in some minor way by a concern for some intangible privacy interest which might be asserted by the individuals named in accident investigation reports, I can assure you that such a belief would be misguided. When I worked fires, I was never aware of anyone considering their names or identities to be confidential or otherwise worthy of secret treatment. On the contrary, the men and women I worked with on fires were proud of what they did and did not feel they had anything to hide from anyone. Moreover, as I said above, I am not aware of any names having ever being withheld from public disclosure in a fire accident investigation report prior to the Cramer Fire Report. I have never been instructed that there is any law that necessitates this; it is certainly not traditional practice.

8. I believe that because the Forest Service is a public agency, it is a reasonable expectation that there will be public disclosure of relevant information when there are injuries or fatalities related to Agency operations. It is prudent to come clean with mistakes, no matter how painful. The Forest Service is a better and wiser agency when it is honest with itself and with the public. Thus, I insisted that the Thirty-Mile Fire report be as full and complete a disclosure as possible of what caused the fatalities, and who was involved in the tragic sequence of actions and decisions. My purpose in doing so is best explained by quoting from the Thirty-Mile Fire report's executive summary:

The investigation team spent many sobering hours here seeking to understand what happened and why, in hopes that a tragedy such as this will never happen again. We labored with respect and honor for those who died, and with a sense of duty to those who will face such a time in their life. We dedicate this report to the hope of lives saved.

9. My many years of experience in the Forest Service have taught me that the full disclosure of relevant information — including the names and responsibilities of all individuals involved — is crucial to allow us to learn from our mistakes as well as to ensure consistent standards of accountability. This holds true both on an organizational as well as on individual level. Moreover, those who fight fires have a keen interest in understanding the capabilities of their supervisors and peers. Fighting wildfires is always dangerous and on occasion, people die. Consequently, those people who choose to put themselves on the line have a right to the best possible information. This includes knowing if their supervisor is known to have a history of poor judgment, or has made decisions causing or contributing to the injury or death of others in their position. I also believe that families have a right to know the names of individuals involved in the death or serious injury of their children, siblings or spouses. Moreover, the public has a right to be informed if its resources are being expended in a safe, efficient and lawful manner, or if mismanagement and lack of accountability are undermining the Agency's mission and threatening its employees.

10. The evaluations of individuals' actions, responsibilities and accountability as presented in the Cramer Fire Report will directly reveal to the public important information pertaining to the competence and character of the named individuals, and also the competence and character of the Forest Service as an organization. One primary function of accident investigation reports is to disseminate important information to the ranks of firefighters and the public. Deleting names of those involved with the Cramer Fire — particularly those responsible for critical decisions — therefore undermines this crucial function. Releasing the Cramer Fire Report with the names deleted prevents full public accountability and understanding of the tragedy and casts an unnecessary and condemning shadow of doubt over an honorable Agency. Given the national basis from which the Forest Service fights fires, it is common for individuals to move across states, even regions, to work different fire events during the same season. Accordingly, it is only with the disclosure of the redacted names contained in the Cramer Fire Report that the public can be assured of the identity of all responsible individuals — and their organizational cohorts — in a manner, which ensures accountability and fire-safety across the entire Forest Service firefighting network. It is only through full disclosure that the public can have confidence that the Forest Service learns from its mistakes and does not allow those responsible for unnecessary death and injury to retain the authority to put others at similar risk. This demonstration cannot occur behind the barriers erected by redactions and secrecy.

11. Moreover, based on my 34-years of experience in the Forest Service, I have concluded that it is only the transparency of operation afforded by the fullest reasonable measure of public accountability that will ensure that the Agency functions effectively and responsibly for its primary constituency; the American public. While there are limited circumstances in which the efficacy of the Agency's operations or respect for a business's or individual's expectation of confidentiality will require the withholding of certain information from public review, such is not the case here. In the matter of the Cramer Fire Report, disclosure of the redacted names will very significantly foster the safe and efficient operation of future Forest Service firefighting efforts as a consequence of the accountability and opportunity for institutional learning which will best occur in an environment informed by public knowledge of all information relevant to these deaths. To the extent that any of the individuals named in the Cramer Fire Report might entertain any expectation of privacy in the withholding of their names from public release — and based on my 34-years of experience in the Agency, I cannot think of a realistic basis to form such an expectation — it is my conclusion that the benefit accruing to the Forest Service in the context of safe and efficient firefighting operations far outweighs the interest of any individual in the withholding of her name. This is particularly true where, as here, the deaths of firefighters have been found to be due, in significant part, to mistakes made by incident commanders and other supervisory personnel at the scene. The Cramer Fire deaths have been the subject of significant public controversy, including the public disclosure that certain of the responsible individuals have been disciplined for their actions during the Fire. In this context — in addition to the other factors noted above — it is in the Agency's best interest to exhibit an attitude of full disclosure and accountability so as best to avoid any cloud which might attach to a suspicion of some sort of "cover-up" related to this tragedy. It is only in this context in which the public can be assured that it is truly aware of the means by which the Forest Service acts to fight fires while assuming the fullest possible responsibility for its employees and public resources.

Pursuant to 28 U.S.C. § 1746, I declare under penalty of perjury that the facts stated above are true and correct:

So executed, this 20th day of April 2005, in Rockville, Maryland.


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