California
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
Cedar Fire
CACNF-003056
CACSR-000132
Southern Region
CONTRIBUTORY FACTORS
Effected the occurrence
or outcome but was not causal. Avoiding or eliminating would not necessarily
prevent the occurrence.
The firing operation from the Inaja Memorial to Santa Ysabel was not
completed on the morning of October 29. It was in this area that the fire
jumped Highway 78/79 and established itself in the San Diego River drainage
on the north side of the highway.
At the time the fire crossed Highway 78/79 between the Inaja Memorial
and Santa Ysabel, aviation assets that were assigned in the Branch III
area, including three fixed-wing air tankers, had been returned to base
due to the inability of the ATGS to contact ground resources.
Engine 6162 was originally placed to shield the portion of the escape
route across the patio to the southeast corner of the house. To facilitate
the burning of brush piles, the engine was moved further south. The net
result was not only an increase in the overall travel distance along the
entire escape route, it also increased the distance that would need to
be covered without the shelter the engine had provided. This exposed the
crew to intense thermal and convective conditions for a longer duration
while traveling the escape route.
An independent firing operation was conducted at 930 Orchard Lane, south
of Engine 6162’s location. The firing operation appears to have
had an effect in drawing both the main fire and the fire at 930 Orchard
together near the accident site, and likely caused a minor but potentially
significant decrease in the amount of time available to react to the changing
conditions. Simulations run without the firing operation indicate that
one to two minutes of additional spread were likely needed for fire to
impinge on the accident site.
It had been the practice on this incident to identify operational safety
concerns as the dynamics of the operation changed. The safety concerns
were communicated from the Safety function to the Operations/Branch and
Division/Group level at the daily operational period briefing. These functions
then verbally communicated both the operational assignments and the safety
message to the ground resources during tailgate briefings at various locations
on the incident. The incident Safety Officer read the safety message at
the operational period briefing on the morning of October 29 and specifically
discussed were the subjects of previously exhibited fire behavior and
changing wind direction. There was not an ICS 215-A completed for the
October 29 operational period, however, there was a generic safety message
contained in each ICS-204 (Division Assignment List) as part of the IAP.
This safety message directed resources on the line to identify and mitigate
hazards.
The fact that all of the crewmembers of Engine 6162 were wearing all
of their Personal Protective Equipment, including nomex shirt/trousers,
gloves, helmet with chinstrap, goggles, protective shroud and Hot Shield
devices (only Captain McDonald and Engineer Rucker had Hot Shields) substantially
lessened the severity of their injuries. Without this protection in place
it is doubtful that the rescue attempt by Captain McDonald, the travel
to the engine by Engineer Kreps, and the eventual escape in the engine
could have taken place without more serious injuries.
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