NIOSH Cedar Fire Report

Summary

Introduction

Investigation & Medical Findings

Recommendations / Discussions

References

Glossary of Terms

Maps and Photographs

CDF Cedar Fire Report

Table of Contents

Review Team Process

Overview of Accident

Summary of Events

Sequence of Events

Findings

Causal Factors

Contributory Factors

Circumstances

Site Conditions

Graphics – List of Illustrations Table

Description of Supporting Data and Supplementary Information

Novato FPD Investigation Analysis

Table of Contents

Prologue

CDF Green Sheet

Overview

Lessons Learned

• ALS Equipment
• Apparatus
• Communications
• Equipment
• Fire Behavior
• Personal Protective Equipment
• Training and Experience
• Policy and Tactics
• Human Factors

Draft Standard Operating Procedures

• Wildland Structure Protection SOP
• Refusal of Risk SOP
• Wildland Firing Operations SOP

Inaja Fire Tragedy

• Introduction
• Sequence of Events
• Conclusion

Acknowledgements

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

REVIEW TEAM PROCESS

I was contacted by Northern Region Chief Dave Driscoll on the afternoon of October 29, 2003 at 3:20 p.m. and advised of a fire fighter fatality on the Cedar Fire in the San Diego Unit. Chief Driscoll contacted me at 4:05 p.m. the same day to confirm my assignment as the Team Leader for the Accident Review Team. I was instructed to report to Monte Vista Headquarters the next afternoon.

While enroute I was in contact with Chief Fred McVay who was assigned to act as liaison between the Southern Region and myself. Chief McVay and I scheduled a briefing for the Accident Review Team at Monte Vista Headquarters for 6:00 p.m. on October 30, 2003.

Chief Alan Stovall was assigned as the Agency Administrator for the Accident Review Team and he and I facilitated the ordering and deployment of the review team members while enroute.

At 3:00 p.m. on October 30, 2003 I was provided an administrator’s briefing from Chief Stovall and Southern Region Chief Tim Turner. This included the jurisdictional authority, review scope, report format, reporting relationships and requirements, time frames, and team composition.

Chief Henri Brachais was assigned as the liaison between Incident Command Team #5 and the review team to facilitate access to necessary documents and personnel. Deputy Chief Jim Barta was assigned as the liaison between the Accident Review Team and San Diego Unit. San Diego Unit provided a Fire Captain to assist with logistical support.

At 6:00 p.m. on October 30, 2003 a briefing was provided to the Accident Review Team at Monte Vista Headquarters training room. This included a summary by Incident Command Team #5 Safety Officer John Simon of the immediate post accident events. Chief Simon also provided documents and maps that were cataloged and a transfer of custody was made to the review team.

At 7:05 p.m. on October 30, 2003 I met with representatives from Federal OSHA and Cal OSHA. We discussed our review process, information available at the time, and made arrangements for them to visit the accident site with members from the Review Team.

An initial team meeting was held at 8:40 p.m. hours on October 30, 2003 with the following items discussed:

Team member roles and responsibilities.
Logistical support needs and processes.
The confidentiality and chain of custody requirements.
Required reports and time frames.
Priority task listing.
Team meeting schedule – twice daily

The team moved to the Hilton Hotel in San Diego where a meeting room and lodging were provided. This remained as the team’s central point of operation through November 9, 2003.

The team was reconvened on November 18-20 at the CDF Northern Region Operations Center in Redding. This meeting was to follow up on action items, continue reviewing the collected data, and work on the elements of the report. At the conclusion of this meeting team members were assigned to draft specific elements of the report. The team met again December 15-16 at the CDF Northern Region Operations Center in Redding. This meeting was to review the draft elements of the report and follow up on action items. The team met again on January 20-22, 2004 at the CDF Northern Region Operations Center in Redding. This meeting was to review and conduct technical edit of report elements, develop final listing for graphics products, and begin assembling the report. During February 2004 team members with responsibility for specific products convened at various venues to complete those products.

In the period between the team meetings members worked on assigned action items and report elements.

The information used in assembling this report was collected through a variety of processes including site observations, witness statements (written), witness interviews (taped / transcribed), aerial photographs, collection of records and historical data, and obtaining photographs and videos taken before, during, and after the incident.

As needed, technical experts were solicited to assist the team. This included stenographic / transcription services, digital mapping and survey, medical opinions, fire weather and fire behavior modeling.

All items (written documentation, tapes, photographs, physical evidence) collected were cataloged and a chain of custody was maintained. Field notes once transferred to supplemental reports and cataloged were destroyed. Sensitive data not pertinent to the report (i.e. - forensic photographs) were sealed and stored along with the physical evidence. Copies of non-sensitive data not pertinent to the report (i.e. – personal photographs) were returned to the owner.

The following reports were generated and submitted by the Review Team: The Preliminary Summary Report (Blue Sheet) was provided to the Agency Administrator at 5:40 p.m. on October 31. The Informational Summary Report (Green Sheet) was provided to the Agency Administrator at 5:01 p.m. on November 7. The Review Report, supporting data, and supplemental information were provided to the Agency Administrator on March 10, 2004.

Submitted by Ken McLean, Review Team Leader

Review Team Membership:

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