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.
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Note: This document was released as
part of the OSHA Cramer Fire inspection file, among about 50 pages
of note-taking sheets used during the interview process. The author
is unknown, but presumably these "lessons learned" were
written by someone within the USFS and familiar with the Salmon-Challis
National Forest and Cramer Fire.
Type 3 Incidents:
Given that the last four burnover fatalities I know of (Cramer,
Kate's Basin,
30 Mile, and South
Canyon) were on Type 3 incidents of one flavor or another,
this seems like a good place to start, and based on what we found with
Cramer, you no doubt know why.
- Top to bottom review of the Type 3 level of organization nationally.
Training, personnel being placed into Type 3 IC positions, the sorts
of incidents being run under a Type 3 organization, the works. Maybe
even go as far as setting up a national working group to address this.
Things to possibly include - mission and intent of the Type 3 level
of organization nationally, training and experience required and adequacy,
the increasing reliance on Type 3 "teams" to take on increasingly
complex incidents, and the inconsistent use of "after-action reviews"
(or close-outs, if you will).
- Come up with some sort of measure of Type 3 IC competency
as a final part of the final certification process. In fire
depts., we do "assessment centers" for Company Officer and
Battalion Chief promotional processes; why not something like that for
the Type 3 IC? OJT and Task Books were a good step in this direction,
but they're still subject to "pencil-whipping" and other inconsistencies.
Some sort of standardized assessment might help bring some problems
to the surface.
My thinking is that with Type 4 or 5, the incident is small enough
that it's not a huge deal to identify problem people and deal with
them immediately. And with Type 2 or 1, the IC is further removed
from line operations, and a questionable IC will not normally be in
a position where he could jeopardize people's safety on the line.
In the case of a Type 3 IC, the incidents tend to be larger, more
complex, and the IC juggling a lot, especially if few of the supporting
positions are filled. It's the most complex organizational level where
the IC is still directly supervising line operations.
- Review of the Task Book system. It's been
ten years since implementation; is it working or is it not? Where are
the weaknesses, what needs to be changed?
- Renewed emphasis on the fundamentals from 130/190
on up. Situational awareness, accountability (including for
self), trigger points, mission-creep, etc.
- Timely and consistent fire weather and behavior
information on all Type 3 incidents. This doesn't necessarily
have to be a fully-qualified FBAN, just someone who can fill this role
at some minimum level of competency.
- No more checklists!! There are too many
as it is, and if four basic things — LCES — were not covered
on the Cramer Fire, the problem is more fundamental.
Maintaining an Experienced Workforce
- Ensure adequate, if not prolific, training opportunities
for people taking on supervisory roles on fires, regardless of seasonal/permanent
status. If they're responsible for people's safety, they should
get top priority! And fire personnel should get priority for fire training
courses.
- End the "Golden Carrot" system. I
know of too many people who held on for years as a seasonal (so far
18 years is the record), hoping for a permanent, full-time appointment,
grasping at periodic "glimmers of hope." Many others moved
on, especially the better ones. There needs to be some way to identify
good people, foster their career development, and give them real, true
opportunities. We need to provide encouragement and tangible opportunities
to the "Heath Hands" of the world, and continue to build their
experience and knowledge base and draw on their abilities.
- Find some way to ensure consistent, adequate funding
for the agencies. Some sort of "buffer" against the
wild swings in funding for fire programs from year to year. I can understand
that in tough times, there's going to be some belt-tightening. However,
Congress itself was the impetus for developing NFMAS, and to fund a
heavy fire-load forest at 50% MEL is insane and irresponsible. Even
if this was increased later, it's impossible to plan for a fire program
that way, and it's not a good way to retain a consistent, reliable,
and competent workforce. If the position was identified as needed, fill
it! And if cuts are to be made, don't make all cuts on the backs of
the seasonal workforce - the ones who actually fight the fires.
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