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
Travel, Rest, and Activity History
At approximately 7:00 p.m., on the evening of October 27, 2003, the Novato
Fire District receives notification from Woodacre Emergency Communications
Center (Marin County) that it is to send a Type III engine to Southern
California to assist with the current wildland fires. A four-person crew
consisting of Captain McDonald, Engineer Kreps, Engineer Rucker and Firefighter-Paramedic
Smith are assigned to staff engine 6162 from an established rotational
During the intervening period prior to actual dispatch at 9:27 p.m.,
the crew begins to collect the items they will need for an extended assignment.
The crew has just returned to shift, at 8:00 a.m., that morning, from
a four-day break. None of the crew has worked any extra shifts during
the preceding few days. That day, Novato fire crews have had a light to
moderate call volume by recount of the on-duty battalion chief. None of
the members have any significant record of sickness or injury from the
Engine 6162 is officially dispatched at 9:27 p.m. by Marin County Communications
and leaves Station Four headed to Southern California. They travel to
the truck scales on eastbound Highway 580 in Livermore where they rendezvous
with the task force leader and the majority of the engines that are to
compose Task Force XAL 2005A. All units leave the area at 12:00 a.m. (now
October 28) with the exception of an additional engine from Vallejo that
is scheduled to meet with the rest of the task force in Santa Nella. A
final engine is added to the task force when they arrive at Cedar Base
According to the strike team’s ICS 214 form and the statements
of Firefighter-Paramedic Smith and Engineer Kreps, the task force makes
several pauses for fuel and rest stops along the drive to the Cedar Fire
incident base (fuel is received at Santa Nella, Interstate 5/Highway 41,
Pasadena). The crew of engine 6162 rotates drivers approximately every
100 miles between Engineer Kreps, Engineer Rucker and Firefighter-Paramedic
Smith. XAL 2005A arrives at Gillespie Field incident base at 11:00 a.m.
on October 28. After check-in with the Resource Unit they are directed
to the Incident Base for food and rest. During this period, Engine 71
(Camp Parks) is added to the task force to give them a total of five engines.
XAL is now designated as a strike team with a strike team leader and assistant
Assignments on October 28, 2003
At 1:15 p.m., on October 28, 2003, Strike Team XAL 2005A is sent to the
area of the intersection of Interstate 8 and Highway 79. Near that location
they undertake a structure protection assignment on Riverview Road (“Camp
Oliver”) where they support a burnout operation. They are told to
hold in the area until 9:30 p.m. that evening to patrol for hot spots.
Photo taken by the crew of Engine 6162
during the first night of activity.
The crew returns to the Gillespie Field staging area at 10:00 p.m., where
they eat dinner and bed down for the evening. Engine 6162 members go to
sleep between 10:30 p.m. and midnight. They arise between 5:00 a.m. and
6:30 a.m. the morning of October 29. By all accounts, they feel rested
and are in good spirits. While the strike team leader attends the morning
(7:00 a.m.), the crew eats breakfast and completes the typical morning
checks on the engine. The pump is run, the pre-trip brake check is completed,
and a general check for operational readiness is conducted. At 8:30 a.m.,
XAL 2005A departs staging and heads for their Branch III, Division I assignment
A Fire Weather Watch was issued at 9:30 a.m. on October 29 by the San
Diego office of the National Weather Service for increasing gusty southwest
to west winds of 15-10 miles per hour in the mountains with locally higher
gusts. The winds were to have increased further during the night time
hours and into Thursday with gusts of 45 to 50 miles per hour with humidity’s
below 15 percent. Later in the afternoon of October 29 (after the accident)
the Fire Weather Watch was upgraded to a Red Flag Warning.
RAWS data from the Julian Station at the approximate time of the accident
indicates average 20foot winds of 17 miles per hour with a peak gust of
31 miles per hour out of 252 degrees, with a temperature reading of 74°F
and 34% relative humidity.
Personal Protective Equipment
The use of personal protective equipment (PPE) by all of the crew members
of Engine 6162 clearly minimized the injuries to the three surviving crew
members. Eyewitness accounts of the accident site and video taken earlier
in the day, along with the documented removal of PPE at the medical treatment
site, indicate that all of the PPE was being worm before and during the
event. The items in the PPE ensemble included: helmet with chinstrap,
goggles, protective shroud, Hot Shield devices (Captain McDonald and Engineer
Rucker), nomex shirt with sleeve liners and pants, web gear with fire
tent shelter, drinking water, gloves and wildland boots
Training and Experience Records Summary
Review of all Training Records and past incident assignments where available,
indicate that nearly all personnel had received the appropriate position
and ancillary training necessary for their particular assignments on the
fire. All operations or line personnel involved with the fatality incident
have had both positional training and functional experience. No training
gaps were found.
There are a few exceptions for Incident Command Team (ICT) personnel,
but those lacking positional training have had previous functional experience.
The notable exception was ICT Safety Officer John Simon. Safety Officer
Simon has not had the 400 level Safety Officer training required for major
command team assignments, only the 200 level (S-204) class. Simon has
had Safety Officer experience on a number of assignments.
All personnel on Engine 6162 had appropriate positional job training.
Experience records provided were in the form of dispatch records, which
list the personnel, dates, times and the general type of response. Experience
records received show the majority of wildland calls had been for grass
or light vegetation, although the run-cards do not contain sufficient
information to support this conclusion. All of the Engine 6162 crew have
had training in wildland urban interface firefighting and fire behavior.
All line personnel including the Strike Team Leader for XAL-2005A, the
Division Group Supervisor, and Branch Directors have had the correct positional
training including intermediate fire behavior.
continue reading—Site Conditions>>>