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,
Request to USFS, December, 2005
FOIA Appeal to USFS,
Management Evaluation Report
Investigation Team Information
Synopsis of the
Cramer Fire Accident Investigation
(facts 1 - 57)
(facts 58 - 201)
(facts 203 - 237)
Resources on the Fire
Cramer Fire Timeline
Fire Behavior and Weather
Equipment Found at H-2 and the Fatalities Site
Fire Policy, Directives, and Guides
OIG FOIA Response,
2nd FOIA Request to OIG,
2nd OIG FOIA Response,
August, 2006, (1.4 mb, Adobe .pdf file)
OSHA Cramer Fire Briefing Paper
• Summary and ToC
• Sections I-IV
• Sections V-VII
• Section VIII
OSHA South Canyon Fire
Letter to District
Ranger, June 19, 2003
OSHA Investigation Guidelines
OSHA News Release
• OSHA Citation 1
• OSHA Citation
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.
Cramer Fire Fatalities
North Fork Ranger District
Salmon-Challis National Forest
Salmon, Idaho - July 22, 2003
Synopsis of the Cramer Fire Accident Investigation
The Salmon-Challis National Forest (SCNF) in the Intermountain Region
(R-4) is located in central Idaho. Rugged, steep terrain on the northern
part of the forest has a significant impact on fire behavior, fuels, and
local weather. On south-southwest aspects, fuels range from scattered
shrubs, grass, and forbs on lower slopes to grass, shrubs and open ponderosa
pine stands at higher elevations. On west-northwest aspects, mixed age
Douglas-fir are prevalent. Live fuel moisture on the forest was at critically
low levels at the time of the Cramer Fire; the Burning Index
(BI) and Energy Release Component (ERC) indicated dangerous conditions.
The SCNF, a high-fire-load forest, has a fire organization, typical for
the region, and delegates decisionmaking and fire management on all but
Type I fires to the ranger districts (RDs). The fire organization was
experiencing some tensions and problems as well as funding and staffing
shortages, but the supervisor's office (SO) and regional office (RO) thought
it worked well overall. The SCNF has a rigorous system of training and
qualifications for its fire management personnel and stressed the importance
of firefighter and public safety as the highest priority in fire suppression
From July 12-22, the SCNF had several ongoing Type II fires as well as
the Type III Cramer Fire. Because the forest fire staff, the North Fork/Middle
Fork district ranger, and the zone duty officer were fully engaged with
large fire management and fire-related business, there was little management
oversight or direction to the Cramer Fire incident commander (IC).
The Cramer Fire became an extended attack fire at approximately 1938
on Sunday, July 20. This should have triggered a need for a complexity
analysis and a wildland fire situation analysis (WFSA). No complexity
analysis or WFSA was prepared on July 20, 21, or 22.
July 19 and 20, 2003
The Cramer Fire, located on the North Fork RD, started on July 19, 2003
from a lightning strike. It was detected by Long Tom Lookout at 1630 on
July 20. At 1648, a McCall, ID, smokejumper aircraft (jumper 41) was diverted
from another fire on the SCNF to do initial attack on the Cramer Fire
but was unable to put smokejumpers on the fire because of high winds.
Jumper 41 estimated the fire at 3 acres, burning in light fuels on a 60-
to 70-percent slope, with a high spread potential.
Later in the evening on July 20, an IC Type IV, an IC Type IV trainee,
and five members of an engine crew were flown into the fire by helicopter
H-166. The engine crew was not used because the central Idaho dispatch
center wanted the crew available for initial attack the next day. Because
of dangerous conditions and darkness, no suppression action was taken
on July 20 other than to assess and monitor the fire.
July 21, 2003
The Cramer Fire was actively burning through the early morning hours
of July 21 and was 35 to 45 acres at 0710. At 1058, the IC Type IV turned
the Cramer Fire over to an IC Type III. During a recon of the fire, the
new IC noted that the perimeter was calm except for the northeast corner.
By late morning, aviation and crew resources began to arrive at the Cove
Creek helibase approximately 13 miles up river from the Cramer Fire. A
Type II initial attack crew was flown from the helibase to a helispot
(H-1) at the base of the fire to begin suppression action on the east
flank, and a Type I helicopter was launched to do bucket work. Late in
the afternoon after returning from an off-forest assignment, a second
helicopter H- 193 from the North Fork RD Indianola helitack base arrived
on the fire with its crew and was asked to do bucket work above H-1.
At 1613 on July 21, fire behavior on the Cramer Fire increased, pushing
the fire east into the Cramer Creek drainage. The hand crew pulled back
to H-1 to hold the line they built above H-1, but the winds blew the fire
across their hand line. At 1735, the IC decided to cease suppression due
to increased fire behavior. The majority of the hand crew walked off the
fire to the Salmon River road while the remainder, including the IC, flew
back to the Cove Creek helibase. Later that evening, Cramer air attack
reported that the fire had grown to 200 acres.
During a conversation later in the evening on July 21 with dispatch,
the forest fire management officer (FMO), and the zone duty officer, the
IC requested two Type II medium helicopters and logistics and operations
support to accomplish his objective of catching the fire at 300 acres
on July 22. He was told that Type II helicopters were ordered but unavailable
and to use a strike team leader the following day to supervise the hand
crews. The logistics support position was filled early on July 22.
July 22, 2003
At 0820 on July 22, the IC reconned the fire with a crew boss and the
assistant manager of H-193. The strategy for the day was to fly three
crews into H-1, use two crews to secure the east flank and one crew to
anchor the fire to the west, and put two rappellers above the fire to
build a helispot (H-2). H-2 would be used to fly a fourth crew in to secure
the west flank of the fire. At 0900, the Type I helicopter was launched
from Indianola to do bucket work on the fire.
At 0943, two Indianola helitack personnel rappelled from H-193 into a
site above the fire to build H-2. The rappel spotter in H-193 estimated
it would take one hour to clear H-2. During the morning and afternoon,
Cove Creek helibase contacted the rappellers on H-2 several times, inquiring
about their progress. The rappellers responded each time that they needed
another 15 minutes to 1 hour before the helispot was completed.
While Cramer air attack was over the fire, he contacted the IC and recommended
using retardant to pretreat the ridge above Cramer Creek and H-2. The
IC confirmed the plan with Cramer air attack. The crew shuttle from the
Cove Creek helibase to H-1 began at 1047. H-166 and H-193 took more than
3 ½ hours to shuttle 60 people-three per helicopter per 15-minute
Lead plane 41 arrived over the Cramer Fire at 1245 while two airtankers
were dropping retardant. Shortly after arriving on the fire, lead plane
41 assumed the duties of air attack because Cramer air attack had returned
to Salmon for refueling. Lead plane 41 noticed small spot fires in the
Cache Bar drainage.
During a recon at 1326, the IC noted that most of the fire activity was
below H-1 but the fire was also active on the east flank. The IC decided
not to put the fourth crew into H-2 because they would have to walk in
dangerous terrain at night. At 1400, fire activity increased and was intense
around H-1, eventually burning over the helispot. At 1423, the IC contacted
the forest FMO with concerns about the fire making a run to the west.
Between 1430 and 1440, the fire that had been smoldering in the Cache
Bar drainage turned into an active flaming front. Between 1500 and 1520,
lead plane 41 observed spread rates and intensities that were much greater
than he expected and thought that the personnel on H-2 would not be at
great risk due to the light fuels and rocky areas in the Cache Bar drainage.
At 1500, H-193 was down for a 30- hour maintenance inspection and H-166
was down for refueling. At 1505, the rappellers on H-2 requested a pick
up and said, "Send them in a hurry." At 1509, the rappellers
again called the helibase requesting the status of their pickup and said,
"We need them right now." At approximately 1510, the Cove Creek
helibase radio operator asked the rappellers on H-2 if they were in danger
and if they needed to go to their safety zone. The rappellers responded
no, it was getting real smoky and they needed a ride out. At 1511 the
strike team leader assembled his three crews, and after 1530, began walking
the crews off the fire to the Salmon River road. At 1512, the Cove Creek
helibase called the rappellers on H-2. When the rappellers responded at
1513, helibase said that the helicopter would be taking off momentarily
and asked if there were any problems. The rappellers on H-2 responded,
"Oh, God. We just got fire down below us. The smoke's coming right
at us. Just make them hurry up."
During this time, the IC was involved in multiple radio conversations
with central Idaho dispatch in Salmon, ID, about using resources assigned
to the Cramer Fire for initial attack on the Stoddard Fire, a new start
close by. H-166 was later diverted from the Cramer Fire to the Stoddard
Fire for initial attack.
At 1520, H-166 said it was coming to get the rappellers at H-2 but couldn't
land because of the smoke. Lead plane 41 heard the rappellers on H-2 respond
to H-166 in a calm voice that the winds were 20 to 25 knots and that they
were leaving H-2. At 1524, the rappellers called and asked, "Could
I get a helicopter up right now?" Lead plane 41 observed that when
the fire in the Cache Bar drainage reached the ridge, some flame lengths
were 50 feet or more with occasional flame lengths up to 100 feet. The
fire, described as "a big flash front," burned over and around
H-2, killing the rappellers shortly after their last radio transmission.
Estimated temperatures at the fatality site were from 1,300 °F to
potentially over 2,000 °F. Two fire shelters were found at the site,
but neither was deployed.
Numerous attempts were made to locate the rappellers after the burnover.
Two personnel were rappelled below H-2 later in the afternoon for a search-and-rescue
mission. Shortly after reaching the ground, the search-and-rescue personnel
were notified by a helicopter over the area that it had located the rappellers
approximately 75 to 100 yards northwest of H-2. The search-and-rescue
personnel flagged and secured the fatalities site. Later on, two more
personnel were delivered close to H-2 and the four spent the night near
At 1008 on July 23, the Lemhi County sheriff, the Lemhi County deputy
sheriff, and a Forest Service employee flew into a helispot above H-2
to remove the bodies. The victims were flown to the Cove Creek helibase
and then on to the Salmon airport. The accident investigation team arrived
in Salmon at 1800.
Forty-four major findings, conclusions developed from the facts of the
incident, were divided into sixteen categories below. Some of the more
significant findings are highlighted and summarized within each category.
Fire Management Plan Direction
The SCNF Fire Management Plan identifies two trigger points that define
when a fire transitions from initial attack to extended attack and what
analyses are needed once a fire reaches extended attack status. It also
addresses the hazards of fire suppression in the Salmon River Breaks and
recognizes that fire line construction at midslope is dangerous and that
underslung fire lines are hard to secure and hold. Midslope fire suppression
tactics were used on the Cramer Fire during extreme burning conditions.
Fire Management Organization
Responsibility for managing Type II through Type V fires was assigned
to the district rangers on the SCNF, which placed a considerable fire
management workload on the North Fork/Middle Fork district ranger. There
was a critical fire management vacancy (the FMO) on the North Fork RD,
and there were no initial attack resources from the North Fork RD on duty
or available when the fire was reported, lengthening the response time.
The SCNF increased the number of positions in its fire organization when
it received additional fire funding, but there were different perceptions
on the forest of how well the fire organization functioned. The performance
of the fire organization was becoming a source of increasing concern,
but limited action was taken to address the state of the fire organization.
Personnel assigned to the Cramer Fire were qualified for their positions.
Transition from Initial Attack to Extended Attack
When the Cramer Fire went into extended attack status, the change from
initial attack to extended attack was not acknowledged, recognized, or
reported by the IC, the North Fork/Middle Fork district ranger, the forest
FMO, or the zone duty officer. As a consequence, the analyses required
by the FMP were not conducted and there was no communication regarding
the change in fire status.
Fire Suppression Strategy and Tactics
There was minimal discussion of Cramer Fire suppression strategy and
tactics among the forest fire staff, the district ranger, the zone duty
officer, and the IC. On July 21 and 22, fire suppression strategy and
tactics on the Cramer Fire did not provide for safe and effective suppression
operations. The IC Type III failed to continually reevaluate the situation
and modify his plan when fire conditions changed and when requested resources
were not available.
There was good attention to safety at the forest level and in the early
stages of the Cramer Fire, however, there were significant safety lapses
on the Cramer Fire prior to the fatalities. Visibility of the slopes below
H-2 was limited by topography and vegetation, obscuring the rappellers'
view of fire below them.
Fire Management Resources
There were inadequate resources and a logistical inability to fully utilize
available resources to implement the ICs’ strategies. On July 22
there was confusion about the availability and positioning of some resources
and helicopters were not available to retrieve the rappellers at a critical
moment of need.
Fire activity on the SCNF increased in July due to hot, dry, weather
and multiple lightning starts, indicating the potential for new starts
to grow rapidly. Crews were informed on the morning of July 22 that conditions
had been progressively warmer and drier the previous two days. Weather
information was not aggressively sought and the information that was obtained
did not represent the Cramer Fire site.
Fuels and Terrain
Fuel and terrain conditions on the Cramer Fire lent themselves to extreme
fire behavior and difficult fire suppression.
Fire Behavior, General
Fire behavior on the Cramer Fire was consistent each day - calm in the
morning and severe in the afternoon. Even though the Salmon River Breaks
are known for their potential extreme fire behavior and some crew members
were aware that seasonal conditions were extreme, other personnel on the
fire did not expect extreme fire behavior in the after- noon of July 22.
There were no effective lookouts for the rappellers at H-2. The plan
for placement of lookouts was not clearly communicated to personnel assigned
to the fire. No lookout with a view of H-2 or the Cache Bar drainage was
posted on July 22 to monitor fire in the Cache Bar drainage and to communicate
critical weather and fire behavior information to the rappellers. Aviation
resources over the fire could not function full time as lookouts for ground
crews given their other duties and responsibilities.
Escape Routes and Safety Zones
Three of the four safety zones identified by the IC and two crew bosses
were not safety zones on the afternoon of July 22, during conditions of
extreme fire behavior. Helicopter retrieval became the primary escape
route to safety for the rappellers.
Fire Behavior, Cache Bar Drainage
The seriousness of the fire in the Cache Bar drainage was underestimated.
Development of an active fire front was observed from the air as much
as 50 minutes before the fire reached H-2, but this information was not
conveyed to the rappellers on H-2. When the fire front reached H-2, the
intensity and rate of spread were much greater than had been anticipated,
and conditions were not survivable with or without a fire shelter.
Multiple attempts were made to contact and locate the rappellers. More
than 30 minutes after loosing contact with the rappellers, the IC became
involved in the search and rescue operation. Prior to that time, he was
checking on the safety of personnel near H-1 and dispatching Cramer Fire
resources to another fire on the forest.
Leadership on the Cramer Fire
Leadership on the Cramer Fire was inadequate to provide for safe and
effective suppression operations. The IC Type III did not request a safety
officer. He remained confident he could contain the fire with the same
strategy even though he did not receive the requested resources, and his
view of the fire on July 22 came from two reconnaissance flights. The
rest of the day he was at the Cove Creek helibase, 13 miles from the Cramer
Fire. When the IC made his decision to retrieve the rappellers from H-2,
½ hour elapsed before a helicopter was launched to get them, and
that launch was requested by the rappellers. During the critical period
prior to and after contact was lost with the rappellers, the IC was also
functioning as the district FMO/AFMO, performing multiple collateral duties.
The SCNF assigned responsibility for the Cramer Fire to the IC Type
III but did not provide oversight. Those who should have provided oversight
focused attention on other priorities. When concerns about management
of the fire surfaced, follow-up on these concerns was inadequate.
Nine causal factors, developed from the findings, are listed below. They
are acts, omissions, conditions, or circumstances that started or sustained
the accident on the Cramer Fire.
1. Management oversight was inadequate.
2. The IC did not adequately perform his duties to execute safe and effective
3. The IC's attention was diverted to issues other than the Cramer Fire.
4. There was a failure to comply with policy.
5. There was a failure to recognize and adjust suppression strategy and
tactics when initial fire suppression efforts failed.
6. There was a failure to accurately assess the fire situation, hazards,
and risks on the Cramer Fire.
7. There was inadequate integration of the H-2 operation into the Cramer
8. There was a delay in formulating and executing a plan to retrieve
the rappellers from H-2.
9. The rappellers were caught in a burnover.
Three contributing factors, developed from the findings, are listed
below. These are factors that set the stage for the accident.
1. The effectiveness of the SCNF fire management organization was impaired.
2. There was a shortage and misallocation of resources.
3. Initial attack was ineffective.