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:
Team Member |
Agency |
Assignment |
Address |
Ken McLean |
California Department of Forestry and Fire Protection |
Team Leader |
875 Cypress Ave Redding, CA. 96001 |
Alan Carlson |
California Department of Forestry and Fire Protection |
Lead Investigator |
604 Antelope Blvd Red Bluff, CA. |
Vince Wall |
California Department of Forestry and Fire Protection |
Safety Program |
P.O. Box 68 Bieber, CA. 96009 |
Carol Jolley |
California Department of Forestry and Fire Protection |
Training Program |
6105 Airport Road Redding, CA. 96002 |
Ethan Foote |
California Department of Forestry and Fire Protection |
Documentation Specialist |
135 Ridgeway Ave Santa Rosa, CA. 95401 |
Kevin Johnston |
Novato Fire Protection District |
Agency Representative |
7025 Redwood Blvd. Novato, CA. 94945 |
David Poucher |
U.S.D.A. Forest Service |
Agency Representative |
1323 Club Drive Vallejo, CA. 94592 |
Tom Oldag |
California Department of Forestry and Fire Protection |
Investigator |
11600 Highway 49 Sutter Creek, CA. 95685 |
Craig Carter |
California Department of Forestry and Fire Protection |
Fire Behavior Analyst |
176 Nelson Ave. Oroville, CA. 95965 |
Norm Silver |
CDF Fire Fighters Local 2881 |
Labor Representative |
443 Marvin Gardens Dr Vacaville, CA. 95687 |
Jeff Whittet |
Novato Local 1775 |
Labor Representative |
7025 Redwood Blvd. Novato, CA. 94945 |
Roger Raines |
CDF Fire Fighters Local 2881 |
Labor Representative |
1393 West Wilson St. Banning, CA. 92220 |
Frank Kemper |
California Department of Forestry and Fire Protection |
G.I.S. Technical Specialist |
135 Ridgeway Ave Santa Rosa, CA. 95401 |
Dave Sapsis |
California Department of Forestry and Fire Protection |
Fuel and Fire Specialist |
1300 U Street Sacramento, CA. 94244-2460 |
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