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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United States
Department of
Agriculture |
Forest
Service |
Washington Office |
14th & Independence SW
P.O. Box 96090
Washington, DC 20090-6090 |
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File Code: 6700
Date: May 4, 2004 |
Mr. Jerrold R. Hockett
Area Director
Occupational Safety and Health Administration
Suite 20101
1150 North Curtis Road
Boise, ID 83706
Dear Mr. Hockett
This letter serves as our Notification of Corrective Action taken as
a result of Inspection Number 117886150. The abatement items for all of
the citations that address the actions of the Type 3 Incident Commanders
are included in the simulation and evaluation process designed and implemented
to determine the incumbent’s ability and test his/her knowledge
on each item. The specific evaluation factors are listed under the abatement
action for each specific item.
Actions taken are as follows:
Region 4 Abatement Action
All Type 3 Incident Commanders (ICT3) in the Intermountain Region
have been required to go through a time-pressure simulation evaluation
process designed and implemented to determine the incumbent’s ability
to make time-critical decisions on fires of increasing complexity, and
test his/her knowledge and application of policy and safe operating practices.
All ICT3’s must successfully complete this evaluation, within two
attempts, to perform ICT3 duties. (Encl 1 & 2)
Other Planned Action
All ICT3s throughout the country must complete this evaluation,
within two attempts, before performing ICT3 duties.
Region 4 Abatement Action
A comprehensive analysis of fire workload, risks, and organizational
resource alternatives was conducted to evaluate the existing fire organization
on the forest. As a result, the Forest has reorganized into a two-zone
fire organization, which will best meet the current and future needs.
This organization will increase efficiency and flexibility, especially
during high fire emergency situations. The organization will increase
the Forest’s ability to provide for adequate backup, and provide
effective forest wide duty officer coverage.
An external review of the Dispatch Office organization and operational
protocols was completed and has resulted in significant changes designed
to improve quality, efficiency, and ultimately the safety of the Forest
operation. To reduce the amount of stress and fatigue associated with
working extended shifts, two additional Dispatch Office positions are
in the process of being advertised and filled by the personnel office.
These new positions will focus on coordination of aviation activities,
intelligence gathering, coordination, and dissemination, thereby allowing
dispatchers to focus on initial attack dispatching and coordination. The
Forest is implementing preplanned dispatch, including pre-approved responses
to better facilitate initial attack and extended attack response.
Region 4 Abatement Action
The Salmon-Challis National Forest completed inspection, calibration,
and maintenance of the Skull Gulch RAWS station utilized to support fire
suppression activities. (Encl 3)
Region 4 Abatement Action
All Type 3 Incident Commanders (ICT3) in the Intermountain Region have
been required to go through a time-pressure simulation evaluation process
designed and implemented to determine the incumbent’s ability to
make time-critical decisions, and test his/her knowledge and application
of policy and safe operating practices. This evaluation included an assessment
of the procedures for ensuring compliance with Lookouts, Communication,
Escape Routes, Safety Zones (LCES), the Ten Standard Firefighting Orders
and the Eighteen Situations That Shout Watch Out. All ICT3’s must
successfully complete this evaluation within two attempts to perform ICT3
duties. (Encl 1 & 2)
Other Planned Action
All ICT3s throughout the country must successfully complete this evaluation
within two attempts before performing ICT3 duties.
Region 4 Abatement Action
The Regional Forester has directed that Intermountain Region District
Rangers who conduct supplemental safety and health inspections on Type
3, 4, and 5 wildland fires will have sufficient Incident Command System
training to conduct these inspections or will be accompanied by someone
with these qualifications. (Encl 4)
Other Planned Action
The Forest Service will, through national policy or interim directive
specify the minimum Incident Command System qualifications for Forest
Supervisors and District Rangers to perform supplemental safety inspection
or that must be present in person(s) with them during the inspection.
Region 4 Abatement Action
All Type 3 Incident Commanders (ICT3) in the Intermountain Region have
been required to go through a time-pressure simulation evaluation process
designed and implemented to determine the incumbent’s ability to
make time-critical decisions, and test his/her knowledge and application
of policy and safe operating practices. This included training on recognition
and mitigation of hazards represented in the Ten Standard Firefighting
Orders and the 18 Situations That Shout Watch Out. All ICT3’s must
successfully complete this evaluation within two attempts to perform ICT3
duties. (Encl 1 & 2)
All supervisory personnel associated with the Cramer Fire fatality have
received letters withholding their “Red Card” certification
until completion of ongoing administrative reviews.
Other Planned Action
All ICT3s throughout the country must complete this evaluation before
performing ICT3 duties.
Region 4 Abatement Action
Direction requiring inclusion of additional safety performance standards
for Forest Supervisors and District Rangers (part of the Thirtymile fire
fatality abatement plan) was promulgated in a letter of Direction, July
3, 2003, signed by the Chief. (Encl 5) The Regional Forester, Intermountain
Region, has ensured that all Forests within the Region comply with this
direction. (Encl 4)
Other Planned Action
A new letter to senior Forest Service leaders restating this requirement
and requiring written assurance of compliance will be sent.
We will keep you informed of our progress completing the Other Planned
Actions.
If you have any questions, or require further documentation, please contact
Mr. Dick King, Director, Safety and Occupational Health at (202) 401-4470.
Sincerely,
/s/ Christopher L. Pyron for
DALE N. BOSWORTH
Chief
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