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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.


Accident Investigation Factual Report

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

Narrative: Postaccident

Fact 203: At 1525, H-166 landed at the Cove Creek helibase to refuel. At about the same time, lead plane 41 departed for McCall, ID, and did not return to the fire (statements: 3, 29, and 37; record: 18).

Fact 204: At 1530, Cramer air attack tried to contact Allen. A minute later, Hackett asked [————] if his crews were together and starting to head down to the Salmon River road. [————] reply was negative — he was still waiting for his crews to assemble. Hackett asked if everything was still safe on that side and [————] replied that everyone was fine (statement: 18; record: 8).

Fact 205: At 1534, H-193 with [————] onboard departed the Cove Creek helibase to pick up Allen and Heath, but was unable to find them because of smoke. [————] reported that the fire had burned the slope below H-2 in the Cache Bar drainage. Trees were torching just below H-2, but there was no crown fire. Smoke was coming out of the Cramer Creek drainage and billowing over H-2, but most of the fire below H-2 in that drainage was a surface fire. When H-193 returned to the Cove Creek helibase [————] formulated a plan for search and rescue (statements: 10, 13, 14, 37, and 41; record: 18).

Fact 206: At 1545, H-166 launched to attack the Stoddard Fire, which had been reported by Long Tom Lookout at 1508 (statements: 3, 5, 13, 14, 20, 29, and 37: record: 18).

Fact 207: At 1550, [————] reported to Hackett that he was at Indianola and asked Hackett if he wanted 133-KA back on the Cramer Fire. When Hackett replied affirmative, he also noted that he had two firefighters with whom he was out of contact. A minute later, Hackett told dispatch that H-166 was leaving for the Stoddard Fire. When asked if he needed the helicopter, Hackett replied that he had the fire covered with H-193 and 133-KA and that anymore aircraft would be a hazard (statements: 4 and 13; record: 8).

Fact 208: In a discussion with Hackett at 1557, Long Tom Lookout noted that H- 193 was patrolling the ridge for Allen and Heath and could not reach Allen and Heath on the air-to-ground frequency. At 1559, Hackett asked Long Tom Lookout if H-193 had made contact with Allen and Heath, and H-193 via Long Tom Lookout responded that he was unable to locate them. At 1600, Hackett notified CID that he had two firefighters on H-2 and was unable to contact them for the last ½ hour. At the same time, H-193 headed back to the Cove Creek helibase. At 1612, Hackett notified CID that H-193 was flying near H-2, they had tried several times to reach the firefighters, and it was smoky. He also reported that helispots H-1 and H-2 had been burned over (statement: 37; record: 8).

Fact 209: 1600 weather: 84 °F, 19-percent relative humidity (record: 9).

Fact 210: By 1609 the fire had reached the ridge between the Cramer Creek and Long Tom Creek drainages (figure 8) (statement: 5).

Fact 211: When CID offered to send H-166 back to the Cramer Fire, Hackett confirmed that he needed H-166 returned. H-166 was sent from the Stoddard Fire to the Cove Creek helibase. At 1617, Hackett asked H-166 to fly the West Ridge again and try to contact Allen on the air-to-ground frequency. Hackett contacted CID and requested that [————] and [————] come to the Cramer Fire (statements: 3 and 37; records: 8, 15, and 18).

Fact 212: At 1625, H-166 tried to locate Allen, Heath, and H-2. At 1638, when H-166 asked Hackett for the direction of the safety zone from H-2, Hackett said it was to the west in the old burn. H-166 responded that he was still unable to locate Allen and Heath, but then immediately confirmed the site of H-2. The area around it was burned over and some trees were torching. At 1642, H-166 reported to Hackett that he was still unable to locate Allen and Heath and was returning to the Cove Creek helibase. [————] reported at 1649 that he had two crews at the Salmon River road and one crew walking down from the fire. Hackett contacted CID at 1654, requesting to have Missoula Life Flight on standby (statement: 37; record: 8).

Fact 213: At 1650, H-193 departed the Cove Creek helibase to search for Allen and Heath (statement: 10; record: 18).

Fact 214: At 1727, a Type I incident management team was ordered for the Cramer Fire (record: 22).

Fact 215: [————] reported at 1730 to the Cove Creek helibase that his crews were heading back. At the same time, H-166 launched with two rappellers, [————] and [————], to conduct a ground search for Allen and Heath (statements: 4, 10, 13, 37, and 41; records: 8 and 18).

Fact 216: A short time later, Cramer air attack departed the fire to refuel and returned at 1839 (records: 8, 15, and 18).

Fact 217: At 1749, Hackett officially turned the Cramer Fire over to [————] (IC Type III) and briefed Henson on the current situation (statement: 14; records: 8 and 15).

Fact 218: At 1755, [————] and [————] rappelled approximately 75 to 150 yards below H-2 to begin their search for Allen and Heath. After [————] and [————] were on the ground and H-166 established contact with them, the helicopter returned to the Cove Creek helibase (statements: 3, 4, 13, 14, and 37; record: 18).

Fact 219: [————] walked up the ridge to H-2 and found gear ready for transport — two chain saws, two Indy gas packs, tools, and a few wedges (appendix d; statements: 4, 10, and 13; record: 21 ).

Fact 220: Allen and Heath had done a great deal of work on the helispot. On the east side of H-2, they felled 15 to 17 - ponderosa pines, some 24 inches DBH and larger, that were on a rocky ridge, with "lots of lean" to them and rot inside. There were at least as many smaller diameter trees, 6 to 8 inches DBH, that had been felled. Approximately the same number and size of trees had been felled on the west side of the ridge (statement: 32; record: 23).

Fact 221: At 1820, H-193 located the bodies of Allen and Heath and guided [————] to the site. [————] remained at H-2. H-193 then returned to the Cove Creek helibase to refuel (statements: 3, 10, 13, 14, 30, and 41; record: 18). -

Fact 222: [————] found the bodies of Jeff Allen and Shane Heath roughly 75 to 100 yards northwest of H-2 up the ridge, away from their safety zones (figure 9) (statements: 3 and 14).

Fact 223: The site contained the remains of two fire shelters, two fire line packs, personal items such as watches, cameras, keys, and belt buckles, and work items such as carabiners, a radio, batteries, and two flight helmets (appendix d; statements: 4 and 41; record 21) .

Fact 224: [————] joined [————] and together they flagged the site. [————] called [————] with a message for [————] on what they found at the site. [————] was distraught and asked to leave (statements: 3, 4, and 13).

Fact 225: [————] a Moyer helitack crewmember, rappelled close to H-2 to spend the night with [————] and provide moral support. It was also too dangerous too late in the day for [————] to walk off the ridge. [————] returned to H-2 to flag off the saws and other equipment. H-166 put an external load of overnight gear into the H-2 area and returned to Moyer (statements: 3, 4, 13, 20, and 37).

Fact 226: At 2020, Cramer air attack reported that the fire had spread into the Long Tom Creek drainage (statement: 18).

Wednesday, July 23, 2003

Fact 227: Around 0600, [————] called dispatch to check on plans for the day (statement: 13).

Fact 228: [————] asked [————] and [————] to locate a helispot for a medium helicopter. [————] located a spot above H-2 on the ridge adjacent to the fatality site and ordered two chain saws (statements: 4 and 13).

Fact 229: At 0912, H-166 launched to deliver the chain saws (statements: 3, 20, and 25).

Fact 230: When the saws arrived, [————] cut the landing spot for the medium helicopter (statement: 13).

Fact 231: Once the site was cut, 133-KA did bucket drops for dust abatement. After assessing the new helispot, H-166 decided to use an alternative site, referred to as H-4, due to safety considerations. At that point, 133-KA was released and H-166 returned to the Cove Creek helibase (statements: 13 and 32).

Fact 232: At approximately 1008, H-166 launched to deliver [————], the Lemhi County sheriff, [————], deputy sheriff, and [————], Forest Service employee, to H-4. While enroute, [————] radioed to [————] and [————] to meet him at H-4 for a flight back to the helibase. After dropping off [————] H-166 returned to the helibase with the two rappellers (statements: 3, 4, 13, 20, 25, and 32).

Fact 233: When [————] and [————] reached H-2, [————] briefed them about the fatality site and a strategy for removing the bodies (statements: 13 and 32).

Fact 234: At 1258 [————] and [————] walked to the fatality site, placed the deceased in body bags, and carried them to the newly cleared helispot. The bodies of Jeff Allen and Shane Heath were flown to the Cove Creek helibase and transferred to a medium helicopter for transport into Salmon, ID. [————] hiked to H-4 for a return flight to the helibase (statements: 13, 20, 25, and 32).

Fact 235: At approximately 1500, [————] secured the fatality site, and when finished, walked to H-4 and flew in H-166 to Indianola (statements: 3 and 32).

Fact 236: At 1510, the bodies of Jeff Allen and Shane Heath were flown on a medium helicopter from the Cove Creek helibase to the Salmon airport (statement: 20).

Fact 237: At 1800, the Cramer Fire accident investigation team arrived in Salmon.

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