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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.


U.S. Department of Labor
Occupational Safety and Health Administration

Inspection Number: 117886150
Inspection Dates: 07/23/2003-08/07/2003
Issuance Date: 03/26/2004

Notice of Unsafe or Unhealthful Working Conditions

Company Name: U.S. Forest Service, Intermountain Region 4
Inspection Site: Cramer Fire, T23N, R15E, Section 20, North Fork, ID 83466

Citation 3 Item 1         Type of Violation: Repeat

29 CFR 1960.11: The agency did not ensure that the performance evaluation of any management official in charge of an establishment, any supervisory employee, or other appropriate management official, measure that employee’s performance in meeting requirements of the agency’s occupational safety and health program:

  1. Performance evaluations did not have elements relating to meeting the requirements of the agency’s safety and health programs for all fire supervisors, fire program management officials, and line officers. Compliance with the Ten Standard Firefighting Orders and Eighteen Watch Out Situations was not included as an element in the 2003 performance evaluation criteria for line officers, fire managers, and fireline supervisors.

    The U.S. Forest Service was previously cited for a violation of this occupational safety and health standard, which was contained in OSHA Inspection Number 303757231, Citation Number 01, Item Number 02, issued on 02/08/2002.

Note: Abatement certification and supporting documentation are required for this item.

Date By Which Violation Must be Abated: 04/21/2004

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