Department of Forestry and Fire Protection
Review Report of Serious CDF Injuries, Illnesses, Accidents
and Near-Miss Incidents
Engine Crew Entrapment, Fatality, and Burn Injuries
October 29, 2003
Any behavior, condition,
act, or omission that starts or sustains an accident occurrence. Avoiding
or eliminating would prevent the occurrence.
Due to fire establishing itself north of Highway 78/79, along the west
side and across the north end of the San Diego River drainage, the decision
was made to re-position ground resources and to defend the structures
along Orchard Lane, including the decision to deploy at the structure
at 920 Orchard Lane.
This action positioned resources on a ridge top (downwind from the
fire for the predicted gradient westerly wind) with unburned fuel between
them and the fire and without the ability to see the fire as it progressed
into and through the drainage. The resources assigned to Orchard Lane
felt the fire was going to be approaching from the north and northwest
and were basing their actions on that expectation.
This also created a transitional situation as the resources changed
geographical areas and tactical environment. The most notable changes
were from direct perimeter control and mop up around structures to one
of structure defense on and near a ridge top with unburned fuel below
The flank of the main fire transitions with a slope reversal accompanied
by a temporary wind shift that, by mass transport of embers, introduces
fire into a receptive fuel bed below the resources along the ridge. As
this fire continues upslope the westerly winds, which were not significant
in the canyon bottom, intercept the fire near the ridge top and change
the fire from a flanking fire to a head fire and push a convective column
from near vertical to near horizontal.
Captain McDonald and Engineer Rucker did not immediately proceed to
the refuge (house) when the order was given.
The full reason for the delay may never be fully explained. Engineer
Rucker fell three times, as he and Captain McDonald proceeded along
the escape route.
There was no assigned/dedicated lookout for operations
on Orchard Lane.
Although resources assigned to operations along Orchard Lane were observing
the fire from their individual vantage points there was not a specified
lookout in position to observe and communicate the status of the flanking
fire’s progress into the drainage, or the establishment of the fire
on the west facing slope of the drainage.
continue reading—Contributory Factors>>>